Clark Fork Valley Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Plains, Montana.
- Location
- 10 Kruger Rd, Plains, Montana 59859
- CMS Provider Number
- 275107
- Inspections on file
- 16
- Latest survey
- February 18, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Clark Fork Valley Nursing Home during CMS and state inspections, most recent first.
A resident with moderate dementia exhibited aggressive behaviors towards others, leading to multiple abuse incidents. Despite documented declines in mood and mobility, the facility failed to implement effective, individualized interventions or conduct thorough investigations. Staff interventions were inconsistent and largely ineffective, highlighting a deficiency in managing the resident's behaviors.
Facility staff failed to perform proper hand hygiene during medication administration and did not use PPE when handling contaminated laundry. A staff member was observed not washing hands between residents, and another did not wear gloves when placing a dirty mop head into the washing machine, despite being aware of the facility's infection control policies.
A resident in a LTC facility repeatedly engaged in aggressive behaviors towards other residents, including running into them with her wheelchair and physically assaulting them, resulting in injuries. Despite multiple incidents, the facility failed to provide adequate protection or manage the resident's behaviors effectively, as revealed through staff interviews and record reviews.
The facility did not report resident-to-resident abuse allegations involving a resident to the State Survey Agency within the required timeframe. Despite multiple abusive interactions documented in the resident's EHR, no reports were made in 2024. Staff interviews revealed a lack of awareness and action, with the abuse coordinator unaware of the incidents. The facility's policy requires immediate reporting of abuse, which was not followed, indicating a significant deficiency in handling abuse allegations.
A facility failed to recognize and investigate repeated aggressive behavior by a resident towards others, resulting in minor injuries. Despite documented altercations in the resident's EHR, no reports were sent to the State Survey Agency. Staff interviews indicated a lack of thorough investigation, and the facility did not follow its policy on reporting and investigating abuse.
The facility inaccurately completed MDS assessments for three residents regarding restraint use, marking side rails as restraints despite residents using them for assistance. Additionally, an antidepressant medication was not correctly identified on a resident's MDS, as Trazodone was used but not coded as an antidepressant. Staff misunderstandings and lack of a specific MDS policy contributed to these deficiencies.
A facility failed to manage expired medications and secure a medication cart, potentially affecting residents. A travel nurse was unable to explain the process for handling expired medications, and expired items were found in the cart. Additionally, the cart was left unlocked and unattended, contrary to facility policy.
A facility failed to include a resident's anticoagulant use and its side effects in her care plan, despite her tendency to bruise easily. Another resident's preference to sleep in a recliner due to claustrophobia was not documented in her care plan, even though she consistently slept in the common area. These omissions highlight deficiencies in the comprehensive care planning for residents.
A facility failed to update a resident's care plan to include comfort care, despite a physician's order. The care plan lacked focus, goals, or interventions related to comfort care. Staff interviews revealed no formal policy existed, and comfort care was based on conversations with families and residents. This deficiency increased the risk of unmet needs for the resident.
The facility failed to implement a bladder function program for two residents, who were frequently incontinent of urine and not on a toileting schedule, despite being able to use the bathroom independently. Facility assessments indicated they were candidates for retraining or scheduled toileting, but no policy or program was in place, as confirmed by staff.
A resident experienced a significant weight loss over three months, but the facility failed to ensure accurate weight records and did not have a process for re-weighing. Despite staff acknowledging the need for re-weighing due to weight changes, no re-weights were conducted, and the facility lacked a formal policy for managing weight changes.
A resident with a history of significant trauma did not receive trauma-informed care at the facility. Despite the resident's disclosures of past traumatic experiences, there was no trauma-informed care plan or social services notes in her records. Staff members acknowledged the resident's history but lacked formal training on trauma-informed care, and the facility did not have a policy or procedure in place for addressing trauma or PTSD.
A resident with a history of traumatic experiences did not receive medically-related social services at the facility. The resident expressed feelings of anger and sadness and reported not having been spoken to by a social worker or therapist. Staff interviews revealed a lack of awareness and action regarding the resident's need for trauma-related support, and no social services notes were found for the resident. The facility's care document indicated that social services should be provided to help residents achieve the highest practicable level of well-being, but this was not implemented for the resident.
A facility failed to limit the use of PRN Ativan for a resident to 14 days or provide a rationale for its extended use. The resident received seven doses over three months without proper documentation or evaluation. Staff interviews revealed a lack of clarity in medication regimen reviews and physician oversight.
The facility did not post a list of names and contact information for state regulatory and advocacy groups, as required. The bulletin board near the nurses' station only had contact information for the state Ombudsman. Staff revealed that the sign was removed during renovations and not replaced. Resident council members were unaware of the sign's location.
The facility did not post the most recent recertification survey results in an accessible area for residents, family members, or staff. During a resident council meeting, members were unaware of the survey results' location. A staff member indicated the information was removed during renovations and not replaced.
Failure to Address Aggressive Behaviors in Dementia Resident
Penalty
Summary
The facility failed to adequately address the aggressive and intrusive behaviors of a resident diagnosed with moderate dementia, leading to multiple resident-to-resident abuse incidents. The resident, who was cognitively impaired and rarely understood others, exhibited a range of aggressive behaviors such as pulling hair, hitting, and spitting at other residents. Despite these behaviors being documented over several months, the facility did not report these events as abuse or conduct thorough investigations, as required by regulations. The resident's Minimum Data Set (MDS) assessments over time showed a decline in her mood, mobility, and independence, with increasing signs of depression and pain. Despite these changes, the facility did not implement person-centered, individualized interventions to address the resident's specific behaviors or the antecedents to these behaviors. The care plan lacked detailed strategies to prevent the resident's aggressive actions and protect other residents, failing to adapt to the resident's deteriorating condition and increased behavioral disturbances. Interviews with staff revealed that interventions for the resident's aggressive behaviors were inconsistent and largely ineffective. Staff noted that the resident became overstimulated quickly and required removal from the environment, but interventions such as medication changes and redirection were not successful in the long term. The facility's documentation did not demonstrate sufficient action to protect other residents or provide ongoing behavioral assessments, highlighting a significant deficiency in the care and management of the resident's dementia-related behaviors.
Inadequate Hand Hygiene and PPE Use During Medication Pass and Laundry Handling
Penalty
Summary
The facility staff failed to adhere to proper hand hygiene protocols during medication administration. A staff member was observed dispensing medications to residents without performing hand hygiene between residents, despite being aware of the facility's policy that requires hand hygiene before and after touching any patient and after touching items in patient rooms. The staff member expressed confusion about the correct process for hand hygiene, indicating a lack of clarity or training on the facility's hand hygiene policy. Additionally, another staff member did not use appropriate personal protective equipment (PPE) when handling contaminated laundry. The staff member was observed placing a dirty mop head into the washing machine without donning gloves or any other PPE, contrary to the facility's guidelines for handling contaminated laundry. The staff member acknowledged the oversight and stated that they had been educated on infection control practices, suggesting a lapse in adherence to established protocols.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from abuse, specifically resident-to-resident abuse incidents involving resident #19, who was identified as the aggressor. Resident #19's electronic medical record documented multiple altercations with other residents, where she exhibited aggressive behaviors such as running into people with her wheelchair, attempting to hit others with objects, and physically assaulting other residents. These incidents resulted in injuries to at least one resident, #10, and affected several others. The report details a series of events where resident #19 engaged in aggressive and harmful behaviors towards other residents. These behaviors included intentionally running into residents with her wheelchair, attempting to hit them with objects like a recliner remote, and physically grabbing and pulling at other residents. Despite these repeated incidents, the facility failed to provide adequate protection to prevent further abuse or to effectively manage resident #19's behaviors. Interviews with staff members revealed a lack of consistent reporting and awareness of the abuse incidents. Staff member P acknowledged that resident-to-resident altercations occurred with resident #19, but there was a lack of comprehensive understanding and communication among staff regarding these incidents. Staff member F noted the difficulty in determining intent in cognitively impaired residents, which contributed to the facility's inadequate response to the abuse. The facility's failure to address these behaviors and protect residents from harm constitutes a significant deficiency in care.
Failure to Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report allegations of resident-to-resident abuse involving a specific resident to the State Survey Agency within the required reporting period. The electronic health record (EHR) of the resident showed multiple interactions with other residents, some of which were abusive and purposeful. Despite these incidents, no reports of resident-to-resident abuse involving this resident were forwarded to the State Survey Agency in 2024. Interviews with staff revealed a lack of awareness and action regarding these incidents, with staff member P documenting the interactions but not ensuring they were reported up the chain of command. Staff member F, the abuse coordinator, was unaware of the abuse allegations and had provided education on abuse reporting, indicating a breakdown in communication and reporting processes. The facility's policy mandates immediate reporting of abuse, neglect, or suspicion thereof, but this was not adhered to in this case. The policy also requires that results of investigations be reported to the State agency within five business days, which was not done. The failure to report these incidents highlights a significant deficiency in the facility's handling of abuse allegations.
Failure to Investigate Resident-to-Resident Abuse
Penalty
Summary
The facility failed to recognize and investigate potential abuse involving a resident who repeatedly engaged in aggressive behavior towards other residents, resulting in minor injuries. Despite multiple resident-to-resident altercations documented in the electronic health record (EHR) of the involved resident, there were no reports of these incidents sent to the State Survey Agency in 2024. Staff interviews revealed that there was a lack of thorough investigation into these altercations, and a staff member had restricted another staff member's access to write progress notes due to concerns about the documentation. The facility's policy on abuse, neglect, and exploitation mandates that all alleged violations, including resident-to-resident incidents, be reported and thoroughly investigated. However, the facility did not adhere to this policy, as evidenced by the absence of social service notes related to the incidents and follow-up for potential victims. The failure to report and investigate these incidents indicates a significant oversight in the facility's responsibility to protect residents from abuse and ensure their safety.
Inaccurate MDS Assessments for Restraint Use and Antidepressant Identification
Penalty
Summary
The facility failed to accurately complete Minimum Data Set (MDS) assessments regarding restraint use for three residents and the identification of an antidepressant medication for one resident. Observations and interviews revealed that three residents used side rails on their beds to assist with repositioning and standing, and they did not perceive these side rails as restraints. However, their MDS assessments inaccurately marked the side rails as daily restraints. The facility did not have a specific written policy for MDS assessments, and staff members were following the Resident Assessment Instrument (RAI) guidelines. A staff member admitted to mistakenly coding the side rails as restraints due to a misunderstanding. Additionally, the facility failed to accurately identify an antidepressant medication for another resident. The resident's Medication Administration Record indicated the use of Trazodone, an antidepressant, for insomnia. However, the resident's Significant Change MDS did not reflect the use of an antidepressant, as it was incorrectly marked as 'No' under the section for high-risk drug classes. A staff member acknowledged the error, confirming that Trazodone is an antidepressant and should have been coded as such on the MDS.
Expired Medications and Unsecured Cart Found in Facility
Penalty
Summary
The facility failed to properly manage expired medications and secure the medication cart, which could potentially affect residents receiving medications. During an observation, a staff member, who was a travel nurse and unfamiliar with the facility's procedures, was unable to explain the process for handling expired medications. Expired medications, including Senna Plus Tablets, Acetaminophen Suppositories, and Glucagon Injection, were found in the medication cart. The facility's policy requires monthly monitoring of expiration dates and the return of expired medications to the pharmacy, but this was not adhered to. Additionally, the medication cart was left unlocked and unattended by the same staff member in the activity/dining room area. The staff member left the cart to walk down the main hallway, leaving medications unsecured in the top drawer. Upon returning, the staff member acknowledged the mistake, stating that the cart should have been locked. The facility's medication administration policy emphasizes the importance of maintaining the security of medications, which was not followed in this instance.
Deficiencies in Comprehensive Care Planning for Residents
Penalty
Summary
The facility failed to ensure a comprehensive care plan for a resident who was on a high-risk medication, specifically an anticoagulant, which was not documented in the care plan. During an observation, a resident was noted to have a bruise on her hand, which she attributed to bumping into her bedside table. The resident mentioned that she bruised easily and often had unexplained bruises. A staff member confirmed that the resident bruised easily and acknowledged that the care plan did not include information about the resident's anticoagulant use or its side effects. A review of the resident's physician orders confirmed the use of apixaban, an anticoagulant, but the care plan lacked any focus, goals, or interventions related to this medication. Additionally, the facility did not account for another resident's sleeping preferences in her care plan. This resident preferred to sleep in a recliner in the common area due to claustrophobia, which made her uncomfortable in her room. Observations and interviews with staff and the resident confirmed that she slept in the common area recliner and felt claustrophobic in her room. However, her care plan did not document her preference to sleep in the recliner or her feelings of claustrophobia, indicating a lack of comprehensive care planning for her needs.
Failure to Revise Care Plan for Comfort Care
Penalty
Summary
The facility failed to revise the care plan for a resident to include comfort care, despite a physician's order dated 10/2/24 indicating the need for such care. The resident's care plan, initiated on 7/25/24, lacked any updates to address comfort care, including focus, goals, or interventions. During the survey, a request for the facility's comfort care policy was made, but no policy was provided. Interviews with staff members revealed that there was no formal comfort care policy or procedure in place. Staff member F indicated that comfort care was based on conversations with the family and resident, while staff member N mentioned that she would discuss comfort care with residents and families and order medications as needed, but was unaware of any existing policy. This lack of a formalized approach increased the risk of the resident's needs being unmet by facility staff.
Lack of Bladder Function Program for Residents
Penalty
Summary
The facility failed to implement a program to maintain or restore bladder function for two residents, leading to a deficiency in care. During interviews, staff member K revealed that the residents were frequently incontinent of urine and were not on a set toileting program or schedule, despite being able to independently use the bathroom. The care plans did not address a toileting schedule or program. Facility assessments indicated that one resident was a good candidate for retraining and could independently manage bathroom tasks, while the other was a candidate for scheduled toileting. Despite requests, no bladder/incontinence policy or bladder retraining program was provided, and staff member F confirmed the absence of such a program or written policies.
Failure to Ensure Accurate Weight Monitoring
Penalty
Summary
The facility failed to ensure accurate and correct weight records for a resident, leading to a significant weight loss that was not properly addressed. The resident, who was observed eating breakfast and reported losing weight since admission, experienced a 13.77% weight loss over three months. Despite this, the facility did not have a process in place for re-weighing the resident, even though staff member C acknowledged the inaccuracy of the weights due to edema and the need for re-weighing if there was a significant weight change. Staff member N expected to be notified of any weight changes, but no re-weighs were conducted, and the physician's progress notes did not address the weight loss or the resident's refusal of a diuretic. The facility lacked a formal policy or procedure for managing weight loss or gain, as confirmed by staff member F. Although a document titled "Long Term Care Weight Management Orders" outlined procedures for weight loss and gain, it was undated, and no re-weights were documented during the period in question. Staff member M expressed concerns about the need for a re-weight but was unsure if these concerns were communicated to the physician. The facility's failure to implement a consistent process for monitoring and addressing significant weight changes contributed to the deficiency.
Failure to Provide Trauma-Informed Care for Resident with Past Trauma
Penalty
Summary
The facility failed to provide trauma-informed care for a resident who had experienced significant past trauma. The resident, identified as #24, shared her history of traumatic experiences, including a childhood with a drug-addicted mother, an abusive marriage, and the murder of her sister. Despite these disclosures, the facility did not have a trauma-informed care plan in place for her, and there were no social services notes in her progress records. Interviews with staff members revealed that the resident frequently spoke about her past trauma, but there was no evidence that she had been assessed for trauma or referred to a counselor or therapist since her admission. Staff members expressed awareness of the resident's traumatic history but indicated a lack of formal training or education on trauma-informed care. One staff member mentioned that the facility had a behavioral counselor available, but it was unclear if the resident had been referred. Additionally, there was no policy or procedure for trauma-informed care or post-traumatic stress disorder available at the facility, highlighting a systemic issue in addressing the needs of residents with traumatic backgrounds.
Failure to Provide Social Services for Resident with Traumatic History
Penalty
Summary
The facility failed to provide medically-related social services to a resident, identified as #24, who had a history of traumatic experiences. During an interview, the resident expressed feelings of anger and sadness when recalling past traumatic events and mentioned that she had not been spoken to by a social worker or therapist since her admission. The resident felt that her experiences were not believed by the staff, despite having shared them with some caregivers. Interviews with staff members revealed a lack of awareness and action regarding the resident's need for trauma-related support. One staff member acknowledged the resident's traumatic past but was unsure if any discussions or assessments had been conducted. Another staff member admitted uncertainty about the existence of a trauma care plan or policy and could not find any social services notes for the resident. The facility's document on care within the long-term care unit indicated that social services should be provided to help residents achieve the highest practicable level of well-being, but this was not implemented for the resident in question.
Failure to Limit PRN Antianxiety Medication Use
Penalty
Summary
The facility failed to ensure compliance with regulations regarding the administration of as-needed (PRN) antianxiety medication for a resident. Specifically, the facility did not limit the use of Ativan, a psychotropic medication, to 14 days or provide a documented rationale for its continued use beyond this period. The resident in question, identified as #24, reported feeling disoriented by a medication she believed was for anxiety, which she did not understand the need for and did not like how it made her feel. The medication orders for Ativan were initiated on September 17, 2024, and discontinued on December 18, 2024, with the resident receiving a total of seven doses over three months. The facility's documentation, including the Consultant Pharmacist's Progress Notes and the physician's progress notes, lacked the necessary evaluation and documentation to justify the extended use of Ativan beyond the 14-day limit. Interviews with staff members revealed a lack of clarity and communication regarding the medication regimen reviews and the physician's role in reviewing and acting on these recommendations. The facility's policy on psychotropic medications required PRN orders to be time-limited and accompanied by a clear rationale, which was not adhered to in this case.
Failure to Post Required Contact Information for State Agencies
Penalty
Summary
The facility failed to post a list of names and contact information for state regulatory and advocacy groups, the State Survey Agency, or State licensure office, which is required for residents wishing to file a complaint. This deficiency was observed during a survey when the bulletin board next to the nurses' station only contained contact information for the state Ombudsman, lacking the complete required information. During interviews, it was revealed that the facility had been provided with a laminated poster containing all necessary information by the state ombudsman office. However, staff member F stated that the sign was removed during renovations at the nurses' station and had not been replaced afterward. Additionally, resident council members were unaware of the location of any sign containing this information.
Failure to Post Recertification Survey Results
Penalty
Summary
The facility failed to post the results of the most recent recertification survey in an area that was easily accessible to residents, family members, residents' legal representatives, or staff. This deficiency was identified during an observation on February 12, 2025, at 7:26 a.m., when no binder containing the survey results was found within the long-term care area of the facility. During a resident council meeting later that day, council members were unaware of the location of the binder with the survey results. Additionally, a staff member revealed that the survey information had been removed during renovations at the nurses' station and had not been replaced afterward.
Latest citations in Montana
A resident with a history of hematuria, renal failure, anemia, and recent blood transfusions was readmitted from the hospital with discharge instructions to pause apixaban, but the facility failed to obtain admission orders and did not clarify the incomplete anticoagulant order. The resident’s care plan did not address anticoagulant use or monitoring, and staff administered multiple doses of apixaban after readmission. Nursing notes documented blood in the nephrostomy drainage bag on two days without provider notification or intervention, followed by worsening weakness, poor intake, and hypoxia that led to hospital transfer. Hospital records showed the resident had gross hematuria, hypotension, respiratory distress, acute kidney injury, and a critically low Hgb requiring transfusion, and a late entry note acknowledged that the discharge order to hold apixaban had been overlooked.
A resident who was cognitively intact but dependent for bowel and bladder care and limited in ROM reported that a specific staff member repeatedly left call lights unanswered for extended periods, causing the resident to soil briefs and then be pressured to ambulate to the bathroom and sign refusal-of-care forms. A family member corroborated long call-light waits and rude interactions, and staff noted the resident became anxious and displayed behaviors when care was forgotten or incomplete. Despite verbal reports, emails, and documentation at a care conference describing long call-light waits, incontinence episodes, and refusal forms used at night, no grievance was filed and the alleged neglect was not reported or investigated. The resident also developed unaddressed skin issues on the heels, coccyx, and ears, and +2 pitting edema in both feet and ankles, with offloading devices found unused in the room and no related wound orders or documented weekly skin assessments.
Multiple residents experienced inadequate pressure ulcer and skin care when staff failed to perform timely and accurate skin assessments, obtain and follow wound care orders, and implement appropriate care plan and nutritional interventions. One resident admitted with multiple skin issues developed a large, foul-smelling coccyx ulcer that was not promptly evaluated, lacked early wound orders, and was not reflected in the care plan or consistently documented on the TAR. Another resident with a coccyx pressure injury and a spinal incision had delayed wound measurements, late dietitian notification, missed daily wound treatments, and late addition of protein supplementation to the care plan. A resident using oxygen had painful, reddened ears and heel/eschar issues that were not captured in admission documentation, lacked wound orders, and had no subsequent skin assessments recorded. A further resident with a coccyx pressure ulcer had conflicting MDS staging and "present on admission" coding, along with numerous days where ordered daily wound care was undocumented or absent. Staff interviews revealed inconsistent weekly skin checks, missed admission skin evaluations due to EHR changes, limited dietitian availability, and wound care being performed by staff without formal wound training, all contrary to the facility’s own skin integrity policy.
The facility failed to thoroughly investigate, monitor, and document multiple abuse allegations involving staff-to-resident and resident-to-resident incidents. In one case, a resident reported that a staff member blew marijuana vape smoke in his face, but there was no related nursing documentation or post-incident monitoring. In another case, a resident reported being hit by another resident, was found with a red mark on the head, and was sent to the ER, yet nursing notes for both residents lacked documentation of the incident and follow-up monitoring. In a third case, a cognitively impaired resident with developmental delay was found in another resident’s room while that resident’s hands were being removed from inside the resident’s pants and shirt, after which the resident complained of pain and was sent to the ER; again, nursing notes for both residents contained no documentation of the event or post-incident monitoring, and the investigator did not fully interview or obtain written statements from all involved as required by facility policy.
The facility failed to thoroughly investigate multiple allegations of abuse and neglect, including one resident’s report that a staff member was verbally demeaning and rushed her during oral care, and another resident’s report of inadequate ADL care with prolonged call light response times and being left in a soiled brief. A staff member admitted not reporting or investigating the latter allegation, and no related documentation was produced. In a separate incident, a resident alleged a CNA turned off the call light and refused requested personal care; the facility interviewed only the involved staff and did not interview other residents who might also have experienced call lights being turned off without care being provided, despite a witness stating this was a common practice by multiple staff. Additional requested interviews and information were not provided to surveyors.
Surveyors found that the facility failed to complete timely and comprehensive baseline care plans for three newly admitted residents. One resident with multiple serious conditions and a coccyx wound had no baseline care plan addressing wound care, pain, or chronic conditions for several days after admission. Another resident with dysphagia, dementia, and documented skin issues on the buttocks, heels, and knee had a baseline care plan that did not identify pressure wounds or related treatments. A third post‑surgical resident with a Stage 3 pressure ulcer and a lumbar incision had a baseline care plan that omitted wound management and post‑operative pain control. A staff member reported that baseline care plans are only generated after the admission nursing assessment is completed and locked, and acknowledged they are not always completed on time.
A resident’s long-time friend, a former employee previously terminated over an abuse allegation, was barred from entering the facility when she attempted to visit, and was told law enforcement would be called if she returned. Another individual confirmed awareness of the restriction, expressed no concern about the friend abusing the resident, and stated that the facility did not offer supervised or common-area visits. A staff member reported that any former employee terminated for an abuse allegation was categorically prohibited from returning to the building, without considering the resident’s relationship with the visitor, despite a visitation policy stating residents have the right to receive visitors of their choice and allowing only limited or supervised access when abuse is suspected or found.
The facility failed to follow its grievance policy by not documenting or investigating a grievance request from a resident and family member alleging that a CNA ignored call lights for extended periods, failed to provide timely ADL care, forced ambulation to the bathroom at night, and pressured the resident to sign refusal-of-care forms, causing the resident to feel afraid and neglected. In a separate case, the facility did not adequately investigate or document a grievance from a dependent, mobility-impaired resident who reported that a male CNA was rough and refused to reposition his contracted legs for comfort, and the staff member assigned to the investigation did not identify the CNA involved or record her explanation of the situation on the grievance form.
A resident reported that a former staff member repeatedly left the call light unanswered for extended periods, did not provide needed ADL assistance, and encouraged the resident to sign refusal-of-care forms, resulting in the resident soiling briefs before being asked to ambulate to the restroom. Another staff member stated that no care concerns had been brought to their attention and acknowledged that the alleged abuse and neglect were not reported. When surveyors requested IDT notes, root cause analysis, reporting, and investigation documents related to the staff member and this resident, the facility was unable to provide any documentation, indicating the allegation was not timely reported to the State Survey Agency or investigated.
Surveyors found that several residents did not receive appropriate ADL and hygiene assistance or accurate documentation of those services. A dependent resident reported inconsistent help with meals, only sponge baths instead of showers for several weeks, lack of shaving, and prior grievances about staff not assisting with a urinal or repositioning his legs. Another cognitively intact resident, dependent for oral care and dressing, stated he was not offered mouthwash or a warm washcloth, and staff confirmed they had never offered mouthwash despite charting that personal hygiene was provided. A third resident, largely independent with self-care, reported that washcloths were not available unless requested, and no washcloths were seen in the room, while documentation showed staff performing most of her personal hygiene. These findings showed failures to offer basic hygiene items and to accurately document ADL care provided.
Failure to Clarify Anticoagulant Orders Leads to Unnecessary Drug Administration and Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s drug regimen was free from unnecessary drugs when nursing staff did not clarify and correctly implement anticoagulant orders upon the resident’s readmission. The resident had been hospitalized for hematuria, renal failure, and anemia, received multiple blood transfusions, and was discharged back to the facility with an After Visit Summary instructing that apixaban (an anticoagulant) be paused, with no restart date specified. Despite this, the facility’s admission documentation for the readmission date showed no admission orders, and the apixaban order was not clarified with the physician. The medication was restarted and administered after readmission, even though the hospital documentation indicated it was to be paused and later discontinued. Following readmission, the resident’s Medication Administration Record showed that seven doses of apixaban were given. The resident’s care plan, initiated on the readmission date, did not identify any problems, goals, or interventions related to anticoagulant use, safety, or monitoring for side effects. Nursing progress notes documented that the resident had a right-sided nephrostomy with yellow urine drainage on the day of readmission, and then documented blood in the nephrostomy drainage bag on two consecutive days. However, there was no documentation that the provider was notified about the hematuria or that any action was taken in response to this change. Subsequently, nursing notes described the resident as weak, not eating, unable to maintain a sitting position, and having low oxygen saturation that did not adequately improve with increased supplemental oxygen, leading to transfer to the emergency department. Hospital records from that visit showed the resident presented with hypoxia, hypotension, profound weakness, respiratory distress, gross hematuria, acute kidney injury, and a critically low hemoglobin of 6.9 g/dL, and that the resident had received an anticoagulant and required blood transfusions. A late entry nursing note at the facility later documented that the hospital discharge summary had been overlooked, the order to hold apixaban was not implemented, and the resident continued to receive apixaban until readmission to the hospital. The facility’s root cause analysis attributed the event to ambiguity in discharge communication and medication reconciliation workflow and noted that the apixaban order was incomplete and not clarified before administration.
Failure to Identify and Address Neglect, Call-Light Delays, and Skin Concerns
Penalty
Summary
The deficiency involves the facility’s failure to identify, report, and address neglect of care concerns for a cognitively intact resident who was dependent on staff for bowel and bladder care and had range of motion limitations in both upper and lower extremities. The resident reported that a specific staff member (NF7) repeatedly left his call light on for extended periods, often over 45 minutes and up to hours at night, resulting in him soiling his brief with bowel and bladder incontinence while waiting for assistance. When staff eventually responded, NF7 would attempt to have the resident ambulate to the restroom despite the resident already being incontinent, and would then encourage him to sign refusal of care forms when he declined. The resident described being upset, anxious, and irritable, and stated he usually “peed” and “soiled” his pants and developed skin issues from sitting so long without being cleaned. A family member (NF6) corroborated concerns about long call light response times, stating the resident’s call light was left on for over an hour, leading to incontinence episodes, and that NF7 spoke to the resident in a rude and angry manner. NF6 reported these concerns in person, by phone, and by email to facility staff, including staff members A and C. Staff member O reported that the resident had anxiety and behaviors that were exacerbated when staff forgot about him or failed to perform all required care. Despite these reports and the resident’s expressed fear and anxiety when NF7 was working, no staff member asked the resident if he felt safe or explored what had occurred on nights with or without NF7, and the alleged neglect was not reported or investigated by facility leadership. The resident also had unaddressed skin concerns and edema that were not properly identified or managed. Staff member B stated weekly skin assessments should have been done but that wound care staff were unaware of any ear or coccyx issues, and the physician orders lacked wound orders for the resident’s left heel. On assessment, staff member P observed eschar on the left heel that appeared to need debridement, redness and cracking on the right heel, pink coccyx, and reddened ears, with delayed capillary refill on one ear, as well as +2 pitting edema in both feet and ankles that had developed during the resident’s stay. Posey boots intended to offload the heels were found in the resident’s cabinet, and staff member P stated she had never seen them used on the resident. Additionally, at a care conference documented and signed by staff member C, the resident reported waiting 20–40 minutes for call lights at night, having accidents while waiting, and being made to sign refusal papers when he declined to go to the bathroom after already being wet. Despite this documentation of neglect-related concerns, no grievance was filed, and staff members B and C stated they were unaware of or did not report or investigate any alleged abuse or neglect for this resident.
Failure to Assess, Document, and Treat Pressure Ulcers and Related Skin Conditions
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain an effective system for pressure ulcer prevention, identification, assessment, and treatment for multiple residents. For one resident admitted with existing skin issues on the buttocks, both heels, and a right knee wound, nursing notes documented a silicone foam dressing on the coccyx that was saturated with foul-smelling brown-yellow drainage, and a non-stageable pressure ulcer with slough, black eschar, and a large reddened border. This was the first detailed description of the coccyx pressure ulcer, and there were no wound care orders in the chart at that time. A subsequent weekly skin evaluation described a large, deep coccyx wound with copious foul-smelling drainage and extensive slough and granulation tissue, but incorrectly listed that date as the first observation despite the wound being identified nine days earlier. Wounds on the left heel, right outer ankle, and right knee were not evaluated until several days after admission, and the right heel was never evaluated during the stay. The resident’s care plan did not identify pressure ulcers as a problem and contained no interventions for pressure ulcer care or nutrition to support wound healing, and the treatment administration record showed wound treatments were not ordered until several days after admission and were then not consistently documented as completed. Another resident was admitted with a coccyx area that was open and possibly caused by pressure, and a late entry note identified a Stage 3 pressure ulcer to the coccyx from admission. However, the nutrition evaluation form later indicated “no” to the presence of a pressure injury and instead listed “other skin condition,” even though coccyx wound care was ordered. The weekly skin evaluation documented the first observation and measurements of the coccyx wound two weeks after admission, and the dietitian was not notified until several days after that. The treatment record showed that daily wound care orders for both the coccyx pressure ulcer and a surgical spine incision were not carried out on at least two days. Nutritional interventions to support wound healing, including a protein supplement, were not added to the care plan until more than two weeks after the wound was identified. Staff interviews revealed that the dietitian was only present in the facility limited hours on two days per week, that residents admitted later in the week might not be assessed nutritionally until the following week, and that a fourteen-day delay in nutritional assessment, while allowed, was acknowledged as not best practice for residents with wounds. A third resident using oxygen reported pain behind both ears, and observation showed that oxygen tubing protectors had slid out of place, leaving the ears unprotected. The right ear was red where the tubing rested, and the left ear was very red with a whitish substance in the crease. Staff later described this resident’s skin as having eschar on the left heel that appeared to need debridement, a red and cracked right heel, a pink coccyx, and reddened ears, with the left ear showing slower capillary refill. The facility’s records contained no wound orders for the left heel, no skin assessments since the most recent readmission, and an admission nursing evaluation that documented the skin as warm, dry, intact, and without wounds. A fourth resident had a coccyx pressure ulcer that was present on admission and gradually decreasing in size according to wound assessments. However, MDS assessments contained inconsistent documentation: one assessment showed no unhealed pressure ulcers on admission, a later discharge assessment documented a Stage IV pressure ulcer present on admission, and a subsequent quarterly assessment documented a Stage III pressure ulcer not present on admission. Treatment administration records showed no coccyx wound treatment in one month, initiation of daily wound care late in the following month with at least one missed documented treatment, and in the next month, daily wound care orders with more than half of the scheduled treatments lacking documentation of completion. In the subsequent month, the TAR failed to show any wound care performed for the coccyx pressure ulcer. Staff interviews indicated that weekly skin checks were the facility practice but were not consistently completed, that nurses were not always coding or documenting wounds correctly, and that admission skin evaluations were sometimes not done due to issues with a new computer system. A staff member performing wound care on one resident’s coccyx reported having no formal wound training and described a wound bed fully covered with thick yellow-tan slough, which, according to the cited National Pressure Ulcer Advisory Panel guideline, could not be accurately staged, despite the facility’s practice of staging it as a Stage III pressure ulcer. The facility’s own Skin Integrity policy required that upon admission, the licensed nurse establish a plan of care based on risk factors or presence of wounds, conduct ongoing weekly full-body skin audits, document new skin impairments with detailed characteristics and measurements, record qualifying wounds on the weekly skin evaluation form, notify the medical provider and obtain treatment orders, notify the resident or representative, notify the registered dietitian, and implement and document appropriate care plan interventions. The findings across these residents showed that these policy steps were not consistently followed: admission and weekly skin evaluations were missed or delayed, wounds were not accurately or timely documented or staged, treatment orders were delayed or not consistently carried out, nutrition and care plan interventions for wound healing and prevention were not promptly implemented, and staff responsible for wound care sometimes lacked formal wound training.
Failure to Thoroughly Investigate and Document Multiple Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to complete thorough investigations, monitoring, and documentation for multiple abuse allegations. In one incident, a resident reported that a staff member blew marijuana vape smoke in his face. The staff member later admitted to vaping marijuana in the resident’s room. Despite this, the resident’s nursing progress notes for the period following the incident contained no documentation of the event or any post-incident monitoring, and the psychosocial impact assessment tool indicated that no ALERT charting had been done by nursing or social services. In a second incident, a resident sitting in a wheelchair by the nurse’s station told a staff member that another resident had hit him; assessment revealed a red mark on the resident’s head, and the resident was sent to the emergency room at the family’s request. However, nursing progress notes for both the alleged victim and the alleged aggressor for the days following the incident contained no documentation of the incident or any post-incident monitoring. The staff member responsible for the investigation stated that he relied on video footage and interviews with the two residents, but these interviews were only documented in the incident report, and no other staff or residents on shift were interviewed. In a third incident, staff found one resident in another resident’s room and observed the second resident removing his hands from inside the first resident’s pants and shirt; the first resident later stated, “It hurts down there,” and was sent to the emergency room. The first resident had diagnoses including unspecified symptoms involving cognitive functions and awareness, anxiety, depression, cerebral infarct, and was described as having a developmental delay with the mentality of an 8-year-old, while the second resident was cognitively intact based on a BIMS score of 14. Nursing progress notes for both residents for the days following the incident contained no documentation of the event or any post-incident monitoring. The staff member overseeing the investigation acknowledged that he did not document his post-incident checks, did not interview staff on shift or other residents, and no abuse education or protective measures for staff were documented, contrary to the facility’s abuse prevention policy that requires interviews with all involved, retrieval of written statements, and documentation of assessments and monitoring.
Failure to Thoroughly Investigate Allegations of Abuse and Neglect
Penalty
Summary
The deficiency involves the facility’s failure to fully investigate multiple allegations of abuse and neglect, including not identifying all potentially affected residents. One resident reported that a staff member (NF8) was “nasty and pushy” while assisting with oral care, telling her she should not take so long brushing her teeth because she only had eight teeth and making her hurry without giving her the time she needed. When the facility questioned NF8 about this incident, he resigned from his position. Review of the facility-reported incident showed no staff interviews were completed as part of the investigation, despite the importance of such interviews in understanding the incident and identifying root causes. Another resident reported inadequate ADL care by staff member NF7, including long call light response times and being left in a soiled brief for hours, and stated he had reported these concerns to facility staff. A staff member later stated they were unaware of any concerns from the resident or his family regarding NF7 and acknowledged they did not report or investigate the alleged abuse or neglect. When surveyors requested documentation such as interdisciplinary team notes, root cause analysis, reporting, and investigation related to concerns with NF7, none was provided. In a separate facility-reported incident, a resident alleged a CNA turned off the call light and refused to provide requested personal care. The facility interviewed only the staff involved that night and did not interview other residents who might have been affected by staff turning off call lights without providing care. A witness (NF5) reported that it was the facility’s usual practice to turn off call lights without providing help, that staff often told the resident they would return but did not always do so, and that multiple staff engaged in this behavior. Despite a request from surveyors, the facility did not provide additional resident interviews or information regarding this allegation by the end of the survey.
Failure to Complete Timely Baseline Care Plans for Wounds and Pain Management
Penalty
Summary
The deficiency involves the facility’s failure to complete timely and comprehensive baseline care plans that provided instructions for resident-centered care for three residents. One resident was admitted with multiple serious diagnoses, including acute kidney failure, anemia, atrial fibrillation, chronic respiratory failure, hypertension, a right femur fracture, morbid obesity, and muscle weakness. A nurse progress note documented a coccyx wound described as stage I open on the day of admission, yet no baseline care plan was initiated to direct staff in caring for the wound, managing pain, or addressing the resident’s chronic medical conditions. A care plan was not started until several days later, and when it was initiated, it only addressed advanced directives, oral/dental health problems, loneliness, and discharge planning, without including wound or pain management. Another resident was admitted with dysphagia, dementia, behaviors, a history of falls, and a urinary tract infection. Nursing progress notes documented skin issues on the buttocks, both heels, and the right knee, but the baseline care plan initiated the same day did not identify pressure wounds or any treatment for those wounds. A third resident, admitted after surgical repair of a lumbar 4 compression fracture, had a documented Stage 3 pressure ulcer and a lower back incision with intact staples on the admission nursing evaluation. However, the baseline care plan for this resident did not include wound management interventions or pain management for post-operative pain. During an interview, a staff member explained that the baseline care plan is triggered when the admitting nurse completes and locks the admission nursing assessment, and acknowledged that when assessments are not locked, baseline care plans are not completed and are not always done on time.
Failure to Honor Resident’s Right to Chosen Visitor
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to receive visitors of her choosing. A long-time friend of the resident, identified as NF1, reported that when she first attempted to visit the resident after the resident’s admission, staff member B escorted her out of the building and told her that law enforcement would be called if she returned. NF1 had previously been employed by the facility approximately four years earlier and had been terminated due to an allegation of abuse toward a resident. The facility did not allow her to visit the resident in any capacity. Another individual, NF2, stated he was aware that the facility was not allowing NF1 to visit the resident and that he knew about the prior abuse allegation but was not concerned about NF1 abusing the resident. NF2 stated he wanted NF1 to be allowed to visit and that the facility did not offer supervised visits or visits in a common area. He was hesitant to raise the visitation issue with the facility because he was concerned it might change how the resident was treated. Staff member B confirmed that any employee terminated due to an abuse allegation was not allowed to return to the building for any reason, and that this restriction was applied without considering the resident’s history with the visitor. The facility’s visitation policy stated residents have the right to receive visitors of their choice and that limitations may include denying or limiting access to individuals suspected of abuse until an investigation is completed or abuse is found, but the facility applied a blanket prohibition in this case.
Failure to Document and Investigate Resident Grievances Alleging Neglect and Inadequate Repositioning
Penalty
Summary
The deficiency involves the facility’s failure to follow its grievance policy and to ensure residents could voice grievances related to alleged abuse and neglect without discrimination or reprisal. One resident reported that a specific CNA (NF7) left his call light on for hours, did not assist with ADLs, and that this led to bowel and bladder incontinence while he waited for help at night. The resident stated that when the CNA finally responded, the CNA would force him to ambulate to the restroom instead of cleaning him in bed, and when the resident refused to ambulate, the CNA told him to sign a refusal of care form. The resident reported being afraid of this CNA and feeling neglected in his care, and he stated he reported these concerns to staff member C. An external email from NF6 to staff member C documented that the resident was afraid of NF7, described NF7’s statements about his job duties, and explicitly requested to file a grievance and have NF7 kept away from the resident. Additionally, a care conference note signed by staff member C documented the resident’s report of being made to sign refusal sheets at night and waiting 20–40 minutes for call lights to be answered. Despite this, staff member C, identified as the grievance official, stated there were no concerns brought forth from the resident or family regarding NF7, and no grievance was completed for this abuse/neglect allegation as required by the facility’s grievance policy. The deficiency also includes the facility’s failure to thoroughly investigate and document findings for another resident’s grievance regarding care. This resident, who had impaired mobility in both upper and lower extremities and was dependent for all ADLs except eating, reported that a night CNA was rough and refused to reposition his legs, and he stated he had complained to the facility but the issue continued. A written grievance from this resident documented that a male CNA would not readjust his legs for comfort. The grievance form’s investigative findings did not show any attempt to identify the specific night CNA involved or to clarify what care was being refused. Staff member E, who was responsible for investigating this grievance, could not recall details of the investigation and acknowledged she did not attempt to identify the accused CNA, characterizing the issue as a recurrent complaint and a miscommunication about repositioning due to the resident’s leg contractures. She stated she had encouraged the resident to be more specific about the repositioning requested but could not explain why this was not documented on the grievance form. The facility’s grievance policy required that grievances, including those involving abuse or neglect, be documented on a grievance form and investigated, but this was not done in accordance with policy for these residents’ complaints.
Failure to Timely Report Alleged Abuse and Neglect to State Agency
Penalty
Summary
The facility failed to timely report an allegation of abuse and neglect to the State Survey Agency involving one sampled resident, identified as resident #47. During an interview, resident #47 reported that a specific former staff member, NF7, would leave his call light on for hours, fail to assist with ADL care, and this lack of response resulted in the resident soiling his brief with bowel and bladder because he waited so long for help. The resident further stated that NF7 would encourage him to sign a refusal of care form and then expect him to ambulate to the restroom after he had already gone in his brief. In a separate interview, staff member B stated that no care concerns from the resident or family had been brought to their attention and acknowledged that they did not report the alleged abuse or neglect of care. A request by surveyors for documentation related to resident #47’s interdisciplinary team notes, any identified root causes, reporting, and investigation of concerns involving NF7 and resident #47 yielded no documentation by the end of the survey, demonstrating a lack of evidence that the allegation was reported or investigated as required.
Failure to Provide and Accurately Document ADL and Hygiene Assistance
Penalty
Summary
Surveyors identified that the facility failed to provide and accurately document assistance with activities of daily living (ADLs) for multiple residents. One resident, who was assessed on the MDS as dependent for all ADLs except eating (requiring only partial to moderate assistance with eating), reported not always receiving help with meals, having only sponge baths for several weeks instead of showers, and needing a shave while observed lying in bed in a hospital gown with several days of facial hair growth. This same resident had previously filed a grievance stating that a night nurse would not assist with use of a urinal despite his inability to do this himself, and that a male CNA would not readjust his legs for comfort. These findings showed a lack of consistent ADL assistance for a resident documented as dependent. Surveyors also found failures related to personal hygiene supplies and documentation for two other residents. One cognitively intact resident, dependent for oral hygiene and dressing, stated he had not been offered mouthwash or a warm washcloth to wash his face that day, and no mouthwash was present in his room; staff later confirmed they had never offered him mouthwash, despite documentation that personal hygiene was offered and that staff did most of the activity. Another resident, who stated she could wash her face, brush her teeth, and comb her hair mostly independently, reported that washcloths were never available unless she specifically asked staff, and on observation there were no washcloths in her room. Her EHR documentation showed staff did most of her personal hygiene activity, while staff later stated she was generally independent and that they had not been giving her a daily washcloth. These discrepancies demonstrated inaccurate ADL documentation and failure to routinely offer basic hygiene items such as washcloths and mouthwash.
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