Continental Care And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Butte, Montana.
- Location
- 2400 Continental Dr, Butte, Montana 59701
- CMS Provider Number
- 275103
- Inspections on file
- 28
- Latest survey
- March 4, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Continental Care And Rehabilitation during CMS and state inspections, most recent first.
Surveyors found that during ongoing plumbing repairs, one end of the kitchen had large sheets of bare, stained plywood laid over missing tile, with surrounding floor areas showing debris and stains. Staff reported that holes had been dug under the flooring to fix drainpipes over the prior two weeks, and that plastic sheeting and tenting were used to contain dust and construction materials. Staff also stated they used plywood to avoid a tripping hazard and were waiting for new tile to arrive. These conditions did not comply with the FDA Food Code and the facility’s sanitation policy requiring cleanable, sanitary nonfood-contact surfaces and clean food service areas.
The facility did not provide meals at scheduled times, resulting in multiple residents waiting extended periods for food, with some meals arriving late and cold. Staff and residents reported ongoing delays, particularly in certain wings, and documentation showed inconsistencies between posted mealtimes and actual service. Staffing issues and process problems contributed to the deficiency, affecting both dining room and in-room meal delivery.
Staff routinely left medications with residents to take on their own without documented safety assessments or physician orders, and care plans did not address self-administration or monitoring. Some residents had cognitive or psychiatric conditions and were unsure about their medications, while staff showed inconsistent understanding of required procedures. Facility policy required interdisciplinary assessment and documentation, which was not completed.
A resident's POLST form indicated Do Not Attempt Resuscitation, but the EHR incorrectly listed the resident as Full Code/Full Treatment. Staff confirmed that social services are responsible for reviewing POLST forms and ensuring accuracy, and facility policy requires documentation and communication of resident choices, but this was not followed, resulting in a mismatch between the resident's wishes and the EHR.
Surveyors found that prescribers did not provide adequate, patient-specific documentation when declining pharmacist-recommended gradual dose reductions (GDR) for psychotropic medications in three cases. Instead, responses were vague or lacked clinical justification, and staff were unaware of proper documentation requirements, resulting in insufficient records to support continued use of these medications.
Multiple residents were observed smoking unsupervised in unauthorized areas, including a blind resident with a history of unsafe smoking and falls. Staff were aware of ongoing violations but did not consistently enforce the facility's no-smoking policy or monitor residents as required. Smoking materials were kept by residents, care plans were incomplete or not followed, and required safety equipment was not used, resulting in increased risk of fire and injury.
A resident with significant vision loss due to cataracts was not properly assessed for vision needs, as staff failed to identify or document the impairment during care conferences and on the MDS. The resident was unable to read or see her food, yet the assessment inaccurately reflected no vision concerns.
A resident with documented bowel and bladder incontinence did not have these conditions addressed in their comprehensive care plan, despite assessment data and facility policy requiring care planning for incontinence. Staff acknowledged the omission and indicated the care plan may not have been completed.
A resident with impaired vision was unable to access necessary eye care and surgery due to the facility's failure to schedule and maintain appointments and arrange timely transportation. Multiple appointments were missed or canceled without proper communication, leading to the resident being refused by provider offices. Staff interviews revealed confusion over scheduling responsibilities, and the resident's care plan lacked interventions for vision needs.
The facility did not ensure that POLST forms were accurately completed for two residents, with one form missing the correct first name and another lacking the required patient or decision-maker signature. Staff confirmed that these forms should be reviewed for accuracy and completeness upon admission and that code status information should be consistent between the POLST and the EHR.
The facility failed to provide therapeutic meals according to physician orders for two dialysis residents. Observations and interviews revealed that meals were high in sodium, contrary to the prescribed renal diets. Residents reported excessively salty food, and staff acknowledged that therapeutic diet orders were not consistently followed, with meals often served late.
The facility failed to provide scheduled showers for three residents, resulting in deficiencies in hygiene care. A resident was found in a filthy condition with a matted ponytail, while another reported infrequent shower offers, often late at night. A third resident indicated a need for a shower, with records showing no showers since admission. These findings highlight the facility's failure to adhere to scheduled hygiene care.
The facility failed to maintain adequate CNA staffing levels, resulting in residents experiencing long wait times for call light responses and missed showers. Staff interviews and observations revealed that insufficient staffing led to delays in meeting residents' needs, with staff often working beyond their shifts without breaks. The facility's actual staffing ratios did not meet the recommended levels, contributing to the deficiencies in resident care.
A resident in a dementia care unit exhibited aggressive behaviors, including physical altercations with another resident and staff, due to the facility's failure to conduct thorough assessments and implement effective interventions. Despite a history of aggression, the resident's care plan was not updated, and behavioral health services were not adequately pursued, leading to ongoing risks for staff and residents.
A facility failed to adhere to professional standards by administering oxycodone and lorazepam concurrently to a resident with COPD, despite warnings of potential side effects. The medications were given together on multiple occasions, although the resident did not have a condition justifying this practice. Staff interviews confirmed awareness of the risks, yet the practice persisted.
The facility failed to maintain sanitary conditions and proper storage in the kitchen, affecting all residents consuming food prepared or stored there. Issues included staff not wearing hairnets, food stored on the floor, a dirty ice machine, expired and undated food items, and a dirty fan pointed towards the dish pit.
The facility failed to complete baseline care plans within the required 48-hour timeframe for 8 out of 25 sampled residents, leading to potential unmet needs. Interviews revealed that the admitting nurse was responsible for initiating these plans, but the facility's policy was not followed.
The facility failed to complete comprehensive, person-centered care plans for four residents requiring oxygen therapy. The care plans lacked necessary details such as the type of oxygen delivery system, when to administer the oxygen, equipment settings, and monitoring of oxygen saturation levels. Staff were also unsure how to access care plans for some residents.
The facility failed to label oxygen tubing and follow physician orders for oxygen administration for two residents. One resident's oxygen tubing was not labeled, and the oxygen concentrator was set incorrectly. Another resident's oxygen concentrator was set higher than the prescribed amount.
The facility failed to serve meals at a palatable temperature for seven residents receiving room trays. Observations and interviews revealed that hot food was often lukewarm or cold by the time it reached the residents' rooms, with inadequate practices for maintaining food temperature during transport.
The facility failed to adhere to infection control practices and proper PPE use during a COVID-19 outbreak involving two residents. Observations showed that the door to the room of two COVID-19 positive residents was left open, and staff did not perform hand hygiene or change PPE when moving between rooms and handling food trays. Despite documented training, staff claimed to have never been educated on proper PPE use.
The facility failed to address the extended duration of antibiotic use for three residents through its Antibiotic Stewardship Program. Despite being aware of the issue, staff reported that prescribing providers refused to discontinue the medications, which did not align with national guidelines or the facility's policy.
The facility failed to update a resident's care plan after the resident, who was severely cognitively impaired, pulled out their PICC line. Despite multiple attempts to contact the facility for more information, no response was received. The care plan was not revised as required by the facility's policy.
The facility failed to follow a dietician's recommendations for a carbohydrate-controlled diet for a resident, resulting in elevated blood sugar levels. The resident was served a meal with higher carbohydrate content than prescribed, and staff confirmed the meal did not meet the dietary order.
The facility failed to ensure accurate MDS assessments for six residents, incorrectly coding bedrails used for mobility as restraints. Staff interviews revealed a lack of understanding regarding the definition of restraints, leading to discrepancies between actual use and documentation.
Unsanitary Kitchen Flooring During Ongoing Plumbing Repairs
Penalty
Summary
Surveyors identified a deficiency related to unsanitary conditions in the kitchen where food was stored, prepared, and served. During observation, two large four-by-eight-foot sheets of bare plywood were found laid over areas of missing tile on one end of the kitchen floor. The plywood had various black stains and was an uncleanable surface that could not be properly maintained for cleanliness. The surrounding tile floor also had scattered debris and white/gray stains. Staff explained that maintenance had dug holes under the flooring to fix drainpipes and that this construction had been ongoing for approximately two weeks, occurring at night when the kitchen was not in use. Staff reported that plastic sheeting and permanent tenting had been hung around the construction areas to contain dust, sand, and concrete debris. One staff member stated he did not know what else to use to cover the missing tile and wanted to avoid creating a tripping hazard. Another staff member stated the floor would be fixed once new tile arrived, expected in about a week. Review of the FDA 2022 Food Code and the facility’s sanitation policy showed requirements that nonfood-contact surfaces be kept free of dust, dirt, food residue, and other debris, and that all food service areas be kept clean, sanitary, and free from litter and rubbish. The observed conditions in the kitchen did not meet these standards.
Failure to Serve Meals at Scheduled Times Resulting in Delayed and Cold Food
Penalty
Summary
The facility failed to provide meals at the regularly scheduled times for five of twenty-five sampled residents, as evidenced by multiple observations and interviews. Residents reported and were observed waiting for extended periods past posted mealtimes, with some meals being delivered up to two hours late. Several residents were found in their rooms or dining areas without food, despite the posted and documented mealtimes indicating when meals should have been served. Staff confirmed that meal delivery was consistently late, particularly for certain wings, and that food was often cold when it finally arrived. Residents expressed dissatisfaction with the timeliness and quality of meal service, with some stating they were forced to order food from outside sources due to hunger or unpalatable, cold meals. Observations showed residents seated with only drinks for prolonged periods, and some residents, such as one who was hungry but had not eaten, had untouched trays delivered late. Staff interviews revealed that dietary staffing fluctuations and process issues contributed to the delays, and that certain wings routinely received meals after others, resulting in predictable lateness for those residents. Documentation provided by the facility showed inconsistencies between posted mealtimes, the mealtime policy, and actual meal delivery times. Staff acknowledged that meal service was not consistent with the documented schedules, and that recent staffing shortages further exacerbated the delays. The deficiency had the potential to affect all residents in the facility, as the late meal service was observed across multiple units and affected both residents in dining rooms and those receiving room trays.
Failure to Assess and Document Resident Safety for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents were properly assessed and found safe to self-administer their own medications before allowing them to do so. Observations revealed that staff routinely left cups of medications at residents' bedsides or on meal trays, allowing residents to take their medications independently without direct supervision. In several cases, residents did not immediately take the medications, and some expressed uncertainty about the purpose of the medications or the conditions they were treating. Record reviews for the affected residents showed that there were no documented assessments for the safety of self-administration of medications, nor were there physician orders authorizing self-administration in the electronic health records (EHRs). Care plans for these residents did not reference their ability to self-administer medications or outline any monitoring procedures. For example, one resident with impaired cognitive function and another with a diagnosis of major depressive disorder and delusional disorders were both left to self-administer medications without documented evaluation of their capacity to do so safely. Interviews with staff revealed inconsistent understanding of the facility's procedures regarding self-administration of medications. While one staff member believed that no physician order or assessment was required, another stated that both were necessary, along with a risk/benefit discussion. The facility's own policy required an interdisciplinary team assessment, documentation in the medical record, and care plan updates for residents self-administering medications, none of which were found in the reviewed cases.
Failure to Accurately Reflect Resident Code Status in EHR
Penalty
Summary
The facility failed to ensure that a resident's code status was accurately reflected in the electronic health record (EHR) in accordance with the resident's completed POLST form. Upon review, the resident's POLST form indicated a preference for Do Not Attempt Resuscitation, while the EHR incorrectly listed the resident as Full Code/Full Treatment. Staff interviews confirmed that social services are responsible for reviewing and ensuring the accuracy of the POLST upon admission, and facility policy requires that any decisions regarding a resident's choices be documented in the medical record and communicated to the care team. However, this process was not followed, resulting in a discrepancy between the resident's documented wishes and the information available to staff in the EHR.
Failure to Document Rationale for Declining Gradual Dose Reductions of Psychotropic Medications
Penalty
Summary
The facility failed to ensure that gradual dose reductions (GDR) for psychotropic medications were attempted or that adequate, patient-specific rationales were documented when GDRs were not performed for three residents. For one resident with dementia, the pharmacist recommended a GDR for Seroquel, but the prescriber declined with only a general statement that the patient was stable, without further clinical justification. Another resident was on Sertraline, and the prescriber responded to the pharmacist's GDR recommendation with a vague comment that "things look good," lacking any specific rationale for maintaining the current dose. A third resident was receiving Duloxetine, Trazodone, and Provigil, and the prescriber declined the pharmacist's GDR recommendations for all three medications without documenting patient-specific reasons for not attempting dose reductions. Additionally, a staff member interviewed was unaware of the documentation requirements for supporting or declining GDRs and was behind on addressing pharmacy recommendations due to personal issues. The facility's policy requires that residents on psychotropic drugs receive GDRs and behavioral interventions unless clinically contraindicated, with clinical rationales documented when GDRs are not attempted. However, the medical records reviewed did not contain adequate documentation to support the continued use of psychotropic medications at the current doses or to explain why GDRs were clinically contraindicated.
Failure to Enforce Smoking Safety Policies and Supervision
Penalty
Summary
The facility failed to follow its own smoking safety policies and procedures for residents who smoke, resulting in multiple deficiencies. Several residents, including one who is blind and at high risk for falls and injury, were observed smoking unsupervised in unauthorized areas, such as immediately outside the activity room door and on the sidewalk, rather than in the designated smoking area. Staff interviews confirmed that residents regularly smoked in these locations, especially during inclement weather, and that staff were aware of the violations but did not consistently intervene or enforce the rules. Cigarette butts were observed littering the ground around these unauthorized smoking areas, indicating ongoing noncompliance. Residents who smoked were not consistently assessed or monitored according to facility policy. One resident, who was blind and had a history of unsafe smoking behavior and prior property damage, was allowed to keep smoking materials in his possession and was not required to sign out when leaving to smoke. His care plan indicated he was unsafe to smoke independently, yet he continued to do so without supervision. Another resident, who required a smoking apron for safety, was not documented as a smoker in his care plan and was observed smoking without the required apron. A third resident reported never being assessed for safe smoking practices and was also observed keeping smoking materials in his room and smoking in unauthorized areas. Staff interviews revealed a lack of consistent enforcement of smoking policies, with some staff deferring responsibility to others or citing resident noncompliance and belligerence as barriers to enforcement. The facility's written policy stated that no accommodations for smoking or tobacco products would be made and that such products were not permitted on the premises, yet this policy was not followed in practice. These failures occurred across multiple shifts and days, involving several staff members and placing residents and others at risk of exposure to second-hand smoke, fire, and injury.
Failure to Accurately Assess Resident's Vision Needs
Penalty
Summary
The facility failed to accurately assess the vision needs of a resident, resulting in an incomplete comprehensive assessment. The resident reported significant vision deterioration since October 2024 due to cataracts and demonstrated an inability to read or see her food during observation. Despite these issues, staff did not identify or address any vision concerns for the resident during care conferences, and no vision needs were documented or reported on the Minimum Data Set (MDS). The MDS inaccurately indicated that the resident could see fine detail and did not use corrective lenses. Facility policy requires comprehensive assessment of vision needs through direct observation and communication, which was not followed in this case.
Failure to Include Bowel and Bladder Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to implement a comprehensive care plan addressing bowel and bladder incontinence for one resident. Review of the resident's Admission MDS indicated that the resident was always incontinent of bowel and bladder, and the Care Area Assessment Summary showed that bladder incontinence had triggered and should have been included in the care plan. The resident's Baseline Care Plan documented frequent incontinence, but the comprehensive care plan did not reflect this condition. During an interview, a staff member acknowledged that bowel and bladder incontinence should be included in the care plan and noted that the resident was relatively new, suggesting the care plan may not have been completed. Facility policy requires the MDS Coordinator and Interdisciplinary Team to review and revise care plans based on resident condition, but this process was not followed for the resident in question.
Failure to Assist Resident with Vision Care Appointments and Transportation
Penalty
Summary
A resident with deteriorating vision experienced significant barriers in accessing necessary vision care services due to the facility's failure to make and maintain timely appointments and arrange appropriate transportation. The resident reported that several appointments had been made and canceled by the facility without her knowledge or notification to the provider offices, resulting in her being late or missing multiple appointments. As a result, some provider offices refused to see her as a patient, and she was unable to receive recommended cataract surgery after being late to a surgeon's appointment. The resident expressed frustration and distress over her inability to participate in activities she enjoyed and her increasing fear of moving around the facility due to her poor eyesight. Interviews with facility staff revealed confusion and lack of communication regarding who was responsible for scheduling and assisting with outside appointments. The new scheduler was unaware of any upcoming vision appointments for the resident, and other staff members either did not know about the resident's vision concerns or denied responsibility for appointment coordination. Review of the resident's care plan showed no documented goals or interventions related to vision appointments, and progress notes contained minimal references to vision care over a six-month period. This lack of coordination and documentation directly contributed to the resident's unmet vision care needs.
Incomplete and Inaccurate POLST Documentation
Penalty
Summary
The facility failed to accurately complete and maintain Physician Orders for Life-Sustaining Treatment (POLST) forms for two residents. For one resident, the POLST form did not contain the resident's correct first name, as it was neither the resident's first name, middle name, nor a name the resident used. For another resident, the required signature of the patient or their decision-maker was missing from the POLST form that was placed in the electronic health record (EHR). Staff interviews confirmed that social services are responsible for reviewing and ensuring the accuracy of POLST forms upon admission, and that the code status on the POLST should match the EHR and be properly signed.
Failure to Provide Therapeutic Meals for Dialysis Residents
Penalty
Summary
The facility failed to provide therapeutic meals that adhered to physician orders for two dialysis residents. Observations and interviews revealed that the meals served to these residents were high in sodium, contrary to their prescribed renal diets. One resident reported that the soup served was excessively salty, and the meal included a roast beef sandwich and a mix of green and kidney beans, which were left untouched. The resident expressed concerns about managing dialysis with a restricted water intake and reported frequent diarrhea. Another resident also noted the saltiness of the food, which included a turkey sandwich with cheese, soup, and saltine crackers. Both residents had physician orders for a renal diet, which requires low sodium intake. Interviews with staff indicated that therapeutic diet orders were not consistently followed, and meals were often served late. The staff member acknowledged that the food trays were similar and did not align with the specific dietary needs of the residents, including those on renal diets. The report references guidelines from the CDC and FDA, highlighting the importance of limiting sodium intake for dialysis patients to prevent complications such as electrolyte imbalances and diarrhea. The failure to provide appropriate meals as per physician orders represents a deficiency in the facility's dietary management for residents requiring therapeutic diets.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to provide scheduled showers for three of the six sampled residents, leading to deficiencies in hygiene care. Resident #1 was reported to have visited another facility in a filthy condition, with significant body odor and a matted ponytail, raising concerns about potential hair loss. Despite being scheduled for showers twice a week, resident #1 only received four showers in the past 30 days, with one documented refusal. Resident #3 reported that his last shower was on a previous Saturday and expressed dissatisfaction with the timing of shower offers, which were often late at night. His electronic health record (EHR) showed a refusal at 3:00 a.m. on the day of the interview, although he stated he rarely refused showers. Resident #8 indicated a need for a shower and stated she had never refused one. Her EHR showed she was scheduled for showers twice a week, but there was no documentation of a shower since her admission. The record showed a refusal on a day not scheduled for a shower and a 'Not Applicable' status on a scheduled day, indicating a lack of showers since admission. These findings highlight the facility's failure to adhere to scheduled hygiene care, resulting in residents not receiving the necessary showers for maintaining personal hygiene.
Inadequate Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to provide adequate staffing levels, particularly Certified Nursing Assistants (CNAs), as per their own facility assessment recommendations. This deficiency resulted in several residents experiencing prolonged wait times for call light responses, with some waiting over 20 minutes. Residents expressed concerns about the long wait times and insufficient staffing, which affected their ability to receive timely assistance for basic needs such as toileting and showers. Specifically, two residents did not receive showers as scheduled, and multiple residents reported waiting times of up to 40 minutes for call light responses. Interviews with staff members revealed that the facility did not maintain records of call light audits, and staff often worked beyond their shifts without breaks due to high resident acuity and low staffing levels. Staff members expressed that the insufficient staffing made it challenging to meet residents' needs effectively, leading to delays in responding to call lights and completing necessary tasks. Observations confirmed that call lights remained unanswered for extended periods, and staff struggled to manage the workload, often leaving late and without taking breaks. The facility's staffing plan outlined a CNA-to-resident ratio of 1:14, but the actual staffing levels did not meet this standard. On the day of the survey, the facility had a census of 86 residents, with staffing ratios falling short of the recommended levels. The C wing had a ratio of 1:15, while the combined A and B wings had a ratio of 1:37 due to a call-off, significantly exceeding the recommended ratio. This discrepancy between the planned and actual staffing levels contributed to the deficiencies observed in resident care and staff workload.
Failure to Address Behavioral Health Needs Leads to Aggression
Penalty
Summary
The facility failed to adequately address the behavioral health care needs of a resident, leading to aggressive incidents involving other residents and staff. Resident #2, who resided in the dementia care unit, exhibited aggressive behaviors, including punching another resident, resident #15, and attempting to hit staff members. Despite these incidents, the facility did not conduct a thorough root cause analysis or implement effective interventions to manage the resident's behavior. Interviews with staff revealed that resident #2 had a history of aggression, including an incident where he placed his hands near a staff member's neck, yet these behaviors were not adequately documented or addressed. The facility's records showed that resident #2 had been agitated and noncompliant, with documented aggressive behavior on multiple occasions. However, there were no updates to his individualized care plan or assessments conducted following these incidents. The care plan lacked person-oriented activities specific to resident #2, and there was no evidence of pain, fall, or behavioral health assessments being completed after the aggressive incidents. Staff interviews indicated that while there were discussions about the resident's behavior, no formal documentation or follow-up actions were taken to address the underlying issues. Additionally, the facility attempted to arrange behavioral health services for resident #2 but faced challenges in securing appointments. A referral for psychiatric services was not completed, and there was a lack of documentation regarding follow-ups with nursing staff about the resident's behaviors. The facility's inaction and lack of comprehensive assessments and interventions contributed to the ongoing aggressive behavior of resident #2, posing a risk to both staff and other residents.
Concurrent Administration of Opioid and Benzodiazepine
Penalty
Summary
The facility failed to meet professional standards of practice by administering an opioid medication, oxycodone, in conjunction with a benzodiazepine, lorazepam, to a resident. This practice was observed despite warnings about the potential for serious side effects, such as respiratory depression and oversedation, especially given the resident's condition of COPD. Interviews with staff revealed that the nursing staff were aware of the risks associated with administering these medications together, yet the medications were still given concurrently on multiple occasions by a specific staff member. The resident involved did not have a diagnosis that would justify the concurrent administration of these medications, such as a seizure disorder or end-of-life care. Despite the facility's medication administration guidelines and the presence of warnings in the Medication Administration Record (MAR), the medications were administered together on several dates. The facility's documentation showed that the staff member responsible had completed competencies in medication management, yet the practice continued, indicating a failure to adhere to professional standards and facility protocols.
Sanitary and Storage Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions and proper storage in the kitchen, which could affect all residents consuming food prepared or stored there. Observations included staff members not wearing hairnets while in designated areas, food items such as hamburger buns, grape juice, and coffee being stored directly on the floor, and a dirty ice machine with a tan and pink film on its plastic surface. Additionally, expired tortilla shells and undated bread were found, indicating a lack of proper food dating and rotation practices. Further observations revealed that food boxes were also stored on the floor of the freezer, and a dirty fan was pointed towards the dish pit, potentially contaminating clean dishes. Interviews with staff members confirmed these practices, with admissions that bread was not dated, the fan was dirty, and the ice machine was cleaned monthly by the maintenance department. Despite the expectation for staff to wear hairnets past a certain point in the kitchen, multiple instances of non-compliance were noted.
Failure to Complete Baseline Care Plans Timely
Penalty
Summary
The facility failed to complete baseline care plans within the required 48-hour timeframe for 8 out of 25 sampled residents. Specifically, the baseline care plans for residents #44, #50, #53, #54, #58, #59, #61, and #221 were not completed on time. For instance, resident #44's care plan was completed four days after the 48-hour window, while resident #50's care plan was completed 52 days late. Other residents experienced delays ranging from three days to 31 days beyond the required timeframe. Interviews with staff members H and B revealed that the responsibility for initiating the baseline care plans lay with the admitting nurse. Staff member B acknowledged that it was her duty to ensure these plans were completed within the 48-hour period. Despite this, the facility's policy on baseline care plans, which mandates their development within 48 hours of admission, was not adhered to, leading to potential unmet needs for the residents.
Deficiency in Comprehensive Care Plans for Oxygen Therapy
Penalty
Summary
The facility failed to complete comprehensive, person-centered care plans for four residents who required oxygen therapy. Resident #37, who used a nasal cannula at two liters, had a care plan that did not specify whether the oxygen was to be intermittent or continuous, if there was oxygen saturation monitoring, or the type of oxygen equipment used. Resident #58, who used a BI-PAP machine at night and required two to three liters of oxygen, had a care plan that lacked person-centered interventions and did not specify the details of oxygen use. Resident #61, who needed two liters of oxygen at all times, had no focus, goals, or interventions addressing the use of oxygen in her care plan. Additionally, staff were unsure how to access the care plan for Resident #61. Resident #5's care plan also failed to specify the amount of oxygen to be administered or when it should be applied. The facility's policies on comprehensive care plans and oxygen administration were not followed, as the care plans did not include necessary details such as the type of oxygen delivery system, when to administer the oxygen, equipment settings, and monitoring of oxygen saturation levels. These omissions were identified through observations, interviews, and record reviews conducted by the surveyors, highlighting a significant deficiency in the facility's ability to provide adequate respiratory care for residents requiring oxygen therapy.
Failure to Label Oxygen Tubing and Follow Physician Orders for Oxygen Administration
Penalty
Summary
The facility failed to label oxygen tubing when it was changed for two residents and did not follow physician orders for prescribed oxygen amounts for two residents. For resident #5, the physician's orders required the oxygen tubing and storage bag to be changed every Sunday and as needed, with the date labeled. However, during an observation, it was noted that there were no labels on the oxygen tubing or equipment for this resident. Similarly, resident #3's oxygen tubing was not labeled with the date, and the oxygen concentrator was set to one and a half liters per minute (lpm) instead of the prescribed two lpm. Additionally, the resident's care plan and physician orders were inconsistent regarding the oxygen amount, with the care plan indicating four lpm and the physician order indicating two lpm. Observations showed the oxygen concentrator set at one and a half lpm on multiple occasions, and the resident was not observed using the oxygen properly during the survey period. For resident #13, the oxygen concentrator was observed to be set at three lpm, while the physician's order specified two lpm. The facility's policy on oxygen administration states that oxygen should be administered under the orders of a physician. These discrepancies indicate a failure to adhere to physician orders and facility policies regarding oxygen administration and equipment labeling, potentially compromising the residents' respiratory care.
Failure to Serve Meals at Palatable Temperatures
Penalty
Summary
The facility failed to serve meals at a palatable temperature for seven residents who received room trays. Multiple residents reported that their hot food was often lukewarm or cold by the time it reached their rooms. Observations confirmed that the food was transferred from the steam table to a thermal insulated food cart without insulated bases for the plates or lids for the bowls. Temperature measurements of the food served to residents showed that the hot food was not maintained at appropriate temperatures, with some items being significantly below the recommended serving temperatures. For example, one resident's white bean soup was measured at 100.5 degrees Fahrenheit, and another resident's tomato soup was measured at 88.5 degrees Fahrenheit. Staff interviews revealed that there were known complaints about the food temperature, and staff members acknowledged that the food was not always warm by the time it reached the residents' rooms. One staff member mentioned that the facility occasionally conducted test trays but was unsure if the food remained warm by the time it was served at the end of the hallway. The facility's current practices for maintaining food temperature during transport were inadequate, leading to the deficiency in serving meals at a palatable temperature for the residents receiving room trays.
Infection Control and PPE Use Deficiencies During COVID-19 Outbreak
Penalty
Summary
The facility failed to adhere to infection control practices and proper PPE use during a COVID-19 outbreak involving two residents. Observations revealed that the door to the room of two COVID-19 positive residents was left open to the hallway, despite one resident frequently coughing. Staff admitted that the door was left open because the resident did not like it closed, although there were no safety risks necessitating this. Additionally, staff were observed not performing hand hygiene or changing PPE when moving between rooms and handling food trays, despite having attended training sessions on these protocols. Interviews with staff indicated a lack of consistent adherence to infection control practices, with one staff member expressing frustration over the daily struggle to enforce proper hand hygiene and PPE use. The facility's policies on hand hygiene and transmission-based precautions were not followed, as evidenced by staff member L's actions of wearing full PPE in the hallway and not performing hand hygiene between tasks. Despite having documented training on these procedures, staff member L claimed to have never been educated on proper PPE use. The facility also failed to provide a requested COVID-19 policy and procedure document during the survey.
Failure to Address Extended Antibiotic Use
Penalty
Summary
The facility failed to address the extended duration of antibiotic use through its Antibiotic Stewardship Program for three residents. Resident #37 had been taking Methenamine Hippurate for 154 days and Macrobid for 20 days without a specified duration or stop date. Resident #26 had been taking Macrobid for 866 days, also without a specified duration or stop date. Despite being aware of the extended use, staff members reported that the prescribing providers refused to discontinue the medications, which did not align with national guidelines or the facility's policy on antibiotic stewardship. The facility's policy required prescribers to provide complete antibiotic orders, including the duration of treatment, which was not followed in these cases. Resident #4 was prescribed Cefadroxil for osteomyelitis and received the medication for four months. The Medication Regimen Review for this resident did not include any recommendations for changes within the specified timeframe. Although research suggests a longer treatment duration for osteomyelitis, the facility's failure to address the extended use of antibiotics for this resident was noted. The facility's policy on antibiotic stewardship was not adhered to, as the orders lacked the required elements such as start and stop dates or the number of days of therapy.
Failure to Update Care Plan for PICC Line
Penalty
Summary
The facility failed to revise and update a resident's care plan to address a PICC line. During an observation and interview, the resident was found sitting in a wheelchair and was unable to answer questions appropriately. The resident's 5-day MDS indicated severe cognitive impairment. Despite multiple attempts to contact the facility for more information, no response was received. The resident's care plan included goals and interventions for IV medication administration via a PICC line, but the care plan was not updated after the resident pulled out the PICC line, as noted in the nursing notes. The facility's policy on care plan revisions upon status change was not followed, leading to the deficiency.
Failure to Follow Carbohydrate-Controlled Diet
Penalty
Summary
The facility failed to ensure that the food served to a resident followed the dietician's recommendations for a carbohydrate-controlled diet. During an observation, the resident was served a ham sandwich with two slices of bread, potato chips, white bean soup with three packages of saltine crackers, and a fruit cup. The resident reported that his blood sugar had been significantly higher since his admission to the facility and attributed this to the increased carbohydrates in his meals. The dietary order for the resident specified a Regular-Carbohydrate Controlled diet, which was not followed. Staff confirmed that the carbohydrate-controlled meal should have included only one slice of bread and two ounces of meat. The resident's blood sugar readings on the day of the observation were elevated, with an average of 228 mg/dL over a ten-day period.
Inaccurate MDS Assessments for Bedrail Use
Penalty
Summary
The facility failed to ensure that resident MDS assessments contained accurate information for six residents. Observations and interviews revealed that several residents had metal bars attached to their beds, which they used for mobility and repositioning. However, these bars were incorrectly coded as restraints in the residents' MDS assessments. For instance, one resident stated that the bars helped her position herself in bed and did not restrict her movement, yet her MDS assessment indicated daily use of restraints. Similar discrepancies were found in the assessments of other residents, where bedrails used for mobility were inaccurately documented as restraints. Staff interviews further highlighted a lack of understanding regarding what constitutes a restraint, with one staff member admitting to being unsure about the definition of restraints and mistakenly coding mobility bars as such. Additionally, the review of physician orders showed no orders for bedrails for some residents, despite their MDS assessments indicating the use of restraints. This inconsistency between the residents' actual use of bedrails and their documentation in the MDS assessments points to a significant issue in the accuracy of resident assessments. The facility's failure to correctly document the use of bedrails and restraints in the MDS assessments could lead to inappropriate care planning and interventions for the residents involved.
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A resident with a history of hematuria, renal failure, anemia, and recent blood transfusions was readmitted from the hospital with discharge instructions to pause apixaban, but the facility failed to obtain admission orders and did not clarify the incomplete anticoagulant order. The resident’s care plan did not address anticoagulant use or monitoring, and staff administered multiple doses of apixaban after readmission. Nursing notes documented blood in the nephrostomy drainage bag on two days without provider notification or intervention, followed by worsening weakness, poor intake, and hypoxia that led to hospital transfer. Hospital records showed the resident had gross hematuria, hypotension, respiratory distress, acute kidney injury, and a critically low Hgb requiring transfusion, and a late entry note acknowledged that the discharge order to hold apixaban had been overlooked.
A resident who was cognitively intact but dependent for bowel and bladder care and limited in ROM reported that a specific staff member repeatedly left call lights unanswered for extended periods, causing the resident to soil briefs and then be pressured to ambulate to the bathroom and sign refusal-of-care forms. A family member corroborated long call-light waits and rude interactions, and staff noted the resident became anxious and displayed behaviors when care was forgotten or incomplete. Despite verbal reports, emails, and documentation at a care conference describing long call-light waits, incontinence episodes, and refusal forms used at night, no grievance was filed and the alleged neglect was not reported or investigated. The resident also developed unaddressed skin issues on the heels, coccyx, and ears, and +2 pitting edema in both feet and ankles, with offloading devices found unused in the room and no related wound orders or documented weekly skin assessments.
Multiple residents experienced inadequate pressure ulcer and skin care when staff failed to perform timely and accurate skin assessments, obtain and follow wound care orders, and implement appropriate care plan and nutritional interventions. One resident admitted with multiple skin issues developed a large, foul-smelling coccyx ulcer that was not promptly evaluated, lacked early wound orders, and was not reflected in the care plan or consistently documented on the TAR. Another resident with a coccyx pressure injury and a spinal incision had delayed wound measurements, late dietitian notification, missed daily wound treatments, and late addition of protein supplementation to the care plan. A resident using oxygen had painful, reddened ears and heel/eschar issues that were not captured in admission documentation, lacked wound orders, and had no subsequent skin assessments recorded. A further resident with a coccyx pressure ulcer had conflicting MDS staging and "present on admission" coding, along with numerous days where ordered daily wound care was undocumented or absent. Staff interviews revealed inconsistent weekly skin checks, missed admission skin evaluations due to EHR changes, limited dietitian availability, and wound care being performed by staff without formal wound training, all contrary to the facility’s own skin integrity policy.
The facility failed to thoroughly investigate, monitor, and document multiple abuse allegations involving staff-to-resident and resident-to-resident incidents. In one case, a resident reported that a staff member blew marijuana vape smoke in his face, but there was no related nursing documentation or post-incident monitoring. In another case, a resident reported being hit by another resident, was found with a red mark on the head, and was sent to the ER, yet nursing notes for both residents lacked documentation of the incident and follow-up monitoring. In a third case, a cognitively impaired resident with developmental delay was found in another resident’s room while that resident’s hands were being removed from inside the resident’s pants and shirt, after which the resident complained of pain and was sent to the ER; again, nursing notes for both residents contained no documentation of the event or post-incident monitoring, and the investigator did not fully interview or obtain written statements from all involved as required by facility policy.
The facility failed to thoroughly investigate multiple allegations of abuse and neglect, including one resident’s report that a staff member was verbally demeaning and rushed her during oral care, and another resident’s report of inadequate ADL care with prolonged call light response times and being left in a soiled brief. A staff member admitted not reporting or investigating the latter allegation, and no related documentation was produced. In a separate incident, a resident alleged a CNA turned off the call light and refused requested personal care; the facility interviewed only the involved staff and did not interview other residents who might also have experienced call lights being turned off without care being provided, despite a witness stating this was a common practice by multiple staff. Additional requested interviews and information were not provided to surveyors.
Surveyors found that the facility failed to complete timely and comprehensive baseline care plans for three newly admitted residents. One resident with multiple serious conditions and a coccyx wound had no baseline care plan addressing wound care, pain, or chronic conditions for several days after admission. Another resident with dysphagia, dementia, and documented skin issues on the buttocks, heels, and knee had a baseline care plan that did not identify pressure wounds or related treatments. A third post‑surgical resident with a Stage 3 pressure ulcer and a lumbar incision had a baseline care plan that omitted wound management and post‑operative pain control. A staff member reported that baseline care plans are only generated after the admission nursing assessment is completed and locked, and acknowledged they are not always completed on time.
A resident’s long-time friend, a former employee previously terminated over an abuse allegation, was barred from entering the facility when she attempted to visit, and was told law enforcement would be called if she returned. Another individual confirmed awareness of the restriction, expressed no concern about the friend abusing the resident, and stated that the facility did not offer supervised or common-area visits. A staff member reported that any former employee terminated for an abuse allegation was categorically prohibited from returning to the building, without considering the resident’s relationship with the visitor, despite a visitation policy stating residents have the right to receive visitors of their choice and allowing only limited or supervised access when abuse is suspected or found.
The facility failed to follow its grievance policy by not documenting or investigating a grievance request from a resident and family member alleging that a CNA ignored call lights for extended periods, failed to provide timely ADL care, forced ambulation to the bathroom at night, and pressured the resident to sign refusal-of-care forms, causing the resident to feel afraid and neglected. In a separate case, the facility did not adequately investigate or document a grievance from a dependent, mobility-impaired resident who reported that a male CNA was rough and refused to reposition his contracted legs for comfort, and the staff member assigned to the investigation did not identify the CNA involved or record her explanation of the situation on the grievance form.
A resident reported that a former staff member repeatedly left the call light unanswered for extended periods, did not provide needed ADL assistance, and encouraged the resident to sign refusal-of-care forms, resulting in the resident soiling briefs before being asked to ambulate to the restroom. Another staff member stated that no care concerns had been brought to their attention and acknowledged that the alleged abuse and neglect were not reported. When surveyors requested IDT notes, root cause analysis, reporting, and investigation documents related to the staff member and this resident, the facility was unable to provide any documentation, indicating the allegation was not timely reported to the State Survey Agency or investigated.
Surveyors found that several residents did not receive appropriate ADL and hygiene assistance or accurate documentation of those services. A dependent resident reported inconsistent help with meals, only sponge baths instead of showers for several weeks, lack of shaving, and prior grievances about staff not assisting with a urinal or repositioning his legs. Another cognitively intact resident, dependent for oral care and dressing, stated he was not offered mouthwash or a warm washcloth, and staff confirmed they had never offered mouthwash despite charting that personal hygiene was provided. A third resident, largely independent with self-care, reported that washcloths were not available unless requested, and no washcloths were seen in the room, while documentation showed staff performing most of her personal hygiene. These findings showed failures to offer basic hygiene items and to accurately document ADL care provided.
Failure to Clarify Anticoagulant Orders Leads to Unnecessary Drug Administration and Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s drug regimen was free from unnecessary drugs when nursing staff did not clarify and correctly implement anticoagulant orders upon the resident’s readmission. The resident had been hospitalized for hematuria, renal failure, and anemia, received multiple blood transfusions, and was discharged back to the facility with an After Visit Summary instructing that apixaban (an anticoagulant) be paused, with no restart date specified. Despite this, the facility’s admission documentation for the readmission date showed no admission orders, and the apixaban order was not clarified with the physician. The medication was restarted and administered after readmission, even though the hospital documentation indicated it was to be paused and later discontinued. Following readmission, the resident’s Medication Administration Record showed that seven doses of apixaban were given. The resident’s care plan, initiated on the readmission date, did not identify any problems, goals, or interventions related to anticoagulant use, safety, or monitoring for side effects. Nursing progress notes documented that the resident had a right-sided nephrostomy with yellow urine drainage on the day of readmission, and then documented blood in the nephrostomy drainage bag on two consecutive days. However, there was no documentation that the provider was notified about the hematuria or that any action was taken in response to this change. Subsequently, nursing notes described the resident as weak, not eating, unable to maintain a sitting position, and having low oxygen saturation that did not adequately improve with increased supplemental oxygen, leading to transfer to the emergency department. Hospital records from that visit showed the resident presented with hypoxia, hypotension, profound weakness, respiratory distress, gross hematuria, acute kidney injury, and a critically low hemoglobin of 6.9 g/dL, and that the resident had received an anticoagulant and required blood transfusions. A late entry nursing note at the facility later documented that the hospital discharge summary had been overlooked, the order to hold apixaban was not implemented, and the resident continued to receive apixaban until readmission to the hospital. The facility’s root cause analysis attributed the event to ambiguity in discharge communication and medication reconciliation workflow and noted that the apixaban order was incomplete and not clarified before administration.
Failure to Identify and Address Neglect, Call-Light Delays, and Skin Concerns
Penalty
Summary
The deficiency involves the facility’s failure to identify, report, and address neglect of care concerns for a cognitively intact resident who was dependent on staff for bowel and bladder care and had range of motion limitations in both upper and lower extremities. The resident reported that a specific staff member (NF7) repeatedly left his call light on for extended periods, often over 45 minutes and up to hours at night, resulting in him soiling his brief with bowel and bladder incontinence while waiting for assistance. When staff eventually responded, NF7 would attempt to have the resident ambulate to the restroom despite the resident already being incontinent, and would then encourage him to sign refusal of care forms when he declined. The resident described being upset, anxious, and irritable, and stated he usually “peed” and “soiled” his pants and developed skin issues from sitting so long without being cleaned. A family member (NF6) corroborated concerns about long call light response times, stating the resident’s call light was left on for over an hour, leading to incontinence episodes, and that NF7 spoke to the resident in a rude and angry manner. NF6 reported these concerns in person, by phone, and by email to facility staff, including staff members A and C. Staff member O reported that the resident had anxiety and behaviors that were exacerbated when staff forgot about him or failed to perform all required care. Despite these reports and the resident’s expressed fear and anxiety when NF7 was working, no staff member asked the resident if he felt safe or explored what had occurred on nights with or without NF7, and the alleged neglect was not reported or investigated by facility leadership. The resident also had unaddressed skin concerns and edema that were not properly identified or managed. Staff member B stated weekly skin assessments should have been done but that wound care staff were unaware of any ear or coccyx issues, and the physician orders lacked wound orders for the resident’s left heel. On assessment, staff member P observed eschar on the left heel that appeared to need debridement, redness and cracking on the right heel, pink coccyx, and reddened ears, with delayed capillary refill on one ear, as well as +2 pitting edema in both feet and ankles that had developed during the resident’s stay. Posey boots intended to offload the heels were found in the resident’s cabinet, and staff member P stated she had never seen them used on the resident. Additionally, at a care conference documented and signed by staff member C, the resident reported waiting 20–40 minutes for call lights at night, having accidents while waiting, and being made to sign refusal papers when he declined to go to the bathroom after already being wet. Despite this documentation of neglect-related concerns, no grievance was filed, and staff members B and C stated they were unaware of or did not report or investigate any alleged abuse or neglect for this resident.
Failure to Assess, Document, and Treat Pressure Ulcers and Related Skin Conditions
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain an effective system for pressure ulcer prevention, identification, assessment, and treatment for multiple residents. For one resident admitted with existing skin issues on the buttocks, both heels, and a right knee wound, nursing notes documented a silicone foam dressing on the coccyx that was saturated with foul-smelling brown-yellow drainage, and a non-stageable pressure ulcer with slough, black eschar, and a large reddened border. This was the first detailed description of the coccyx pressure ulcer, and there were no wound care orders in the chart at that time. A subsequent weekly skin evaluation described a large, deep coccyx wound with copious foul-smelling drainage and extensive slough and granulation tissue, but incorrectly listed that date as the first observation despite the wound being identified nine days earlier. Wounds on the left heel, right outer ankle, and right knee were not evaluated until several days after admission, and the right heel was never evaluated during the stay. The resident’s care plan did not identify pressure ulcers as a problem and contained no interventions for pressure ulcer care or nutrition to support wound healing, and the treatment administration record showed wound treatments were not ordered until several days after admission and were then not consistently documented as completed. Another resident was admitted with a coccyx area that was open and possibly caused by pressure, and a late entry note identified a Stage 3 pressure ulcer to the coccyx from admission. However, the nutrition evaluation form later indicated “no” to the presence of a pressure injury and instead listed “other skin condition,” even though coccyx wound care was ordered. The weekly skin evaluation documented the first observation and measurements of the coccyx wound two weeks after admission, and the dietitian was not notified until several days after that. The treatment record showed that daily wound care orders for both the coccyx pressure ulcer and a surgical spine incision were not carried out on at least two days. Nutritional interventions to support wound healing, including a protein supplement, were not added to the care plan until more than two weeks after the wound was identified. Staff interviews revealed that the dietitian was only present in the facility limited hours on two days per week, that residents admitted later in the week might not be assessed nutritionally until the following week, and that a fourteen-day delay in nutritional assessment, while allowed, was acknowledged as not best practice for residents with wounds. A third resident using oxygen reported pain behind both ears, and observation showed that oxygen tubing protectors had slid out of place, leaving the ears unprotected. The right ear was red where the tubing rested, and the left ear was very red with a whitish substance in the crease. Staff later described this resident’s skin as having eschar on the left heel that appeared to need debridement, a red and cracked right heel, a pink coccyx, and reddened ears, with the left ear showing slower capillary refill. The facility’s records contained no wound orders for the left heel, no skin assessments since the most recent readmission, and an admission nursing evaluation that documented the skin as warm, dry, intact, and without wounds. A fourth resident had a coccyx pressure ulcer that was present on admission and gradually decreasing in size according to wound assessments. However, MDS assessments contained inconsistent documentation: one assessment showed no unhealed pressure ulcers on admission, a later discharge assessment documented a Stage IV pressure ulcer present on admission, and a subsequent quarterly assessment documented a Stage III pressure ulcer not present on admission. Treatment administration records showed no coccyx wound treatment in one month, initiation of daily wound care late in the following month with at least one missed documented treatment, and in the next month, daily wound care orders with more than half of the scheduled treatments lacking documentation of completion. In the subsequent month, the TAR failed to show any wound care performed for the coccyx pressure ulcer. Staff interviews indicated that weekly skin checks were the facility practice but were not consistently completed, that nurses were not always coding or documenting wounds correctly, and that admission skin evaluations were sometimes not done due to issues with a new computer system. A staff member performing wound care on one resident’s coccyx reported having no formal wound training and described a wound bed fully covered with thick yellow-tan slough, which, according to the cited National Pressure Ulcer Advisory Panel guideline, could not be accurately staged, despite the facility’s practice of staging it as a Stage III pressure ulcer. The facility’s own Skin Integrity policy required that upon admission, the licensed nurse establish a plan of care based on risk factors or presence of wounds, conduct ongoing weekly full-body skin audits, document new skin impairments with detailed characteristics and measurements, record qualifying wounds on the weekly skin evaluation form, notify the medical provider and obtain treatment orders, notify the resident or representative, notify the registered dietitian, and implement and document appropriate care plan interventions. The findings across these residents showed that these policy steps were not consistently followed: admission and weekly skin evaluations were missed or delayed, wounds were not accurately or timely documented or staged, treatment orders were delayed or not consistently carried out, nutrition and care plan interventions for wound healing and prevention were not promptly implemented, and staff responsible for wound care sometimes lacked formal wound training.
Failure to Thoroughly Investigate and Document Multiple Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to complete thorough investigations, monitoring, and documentation for multiple abuse allegations. In one incident, a resident reported that a staff member blew marijuana vape smoke in his face. The staff member later admitted to vaping marijuana in the resident’s room. Despite this, the resident’s nursing progress notes for the period following the incident contained no documentation of the event or any post-incident monitoring, and the psychosocial impact assessment tool indicated that no ALERT charting had been done by nursing or social services. In a second incident, a resident sitting in a wheelchair by the nurse’s station told a staff member that another resident had hit him; assessment revealed a red mark on the resident’s head, and the resident was sent to the emergency room at the family’s request. However, nursing progress notes for both the alleged victim and the alleged aggressor for the days following the incident contained no documentation of the incident or any post-incident monitoring. The staff member responsible for the investigation stated that he relied on video footage and interviews with the two residents, but these interviews were only documented in the incident report, and no other staff or residents on shift were interviewed. In a third incident, staff found one resident in another resident’s room and observed the second resident removing his hands from inside the first resident’s pants and shirt; the first resident later stated, “It hurts down there,” and was sent to the emergency room. The first resident had diagnoses including unspecified symptoms involving cognitive functions and awareness, anxiety, depression, cerebral infarct, and was described as having a developmental delay with the mentality of an 8-year-old, while the second resident was cognitively intact based on a BIMS score of 14. Nursing progress notes for both residents for the days following the incident contained no documentation of the event or any post-incident monitoring. The staff member overseeing the investigation acknowledged that he did not document his post-incident checks, did not interview staff on shift or other residents, and no abuse education or protective measures for staff were documented, contrary to the facility’s abuse prevention policy that requires interviews with all involved, retrieval of written statements, and documentation of assessments and monitoring.
Failure to Thoroughly Investigate Allegations of Abuse and Neglect
Penalty
Summary
The deficiency involves the facility’s failure to fully investigate multiple allegations of abuse and neglect, including not identifying all potentially affected residents. One resident reported that a staff member (NF8) was “nasty and pushy” while assisting with oral care, telling her she should not take so long brushing her teeth because she only had eight teeth and making her hurry without giving her the time she needed. When the facility questioned NF8 about this incident, he resigned from his position. Review of the facility-reported incident showed no staff interviews were completed as part of the investigation, despite the importance of such interviews in understanding the incident and identifying root causes. Another resident reported inadequate ADL care by staff member NF7, including long call light response times and being left in a soiled brief for hours, and stated he had reported these concerns to facility staff. A staff member later stated they were unaware of any concerns from the resident or his family regarding NF7 and acknowledged they did not report or investigate the alleged abuse or neglect. When surveyors requested documentation such as interdisciplinary team notes, root cause analysis, reporting, and investigation related to concerns with NF7, none was provided. In a separate facility-reported incident, a resident alleged a CNA turned off the call light and refused to provide requested personal care. The facility interviewed only the staff involved that night and did not interview other residents who might have been affected by staff turning off call lights without providing care. A witness (NF5) reported that it was the facility’s usual practice to turn off call lights without providing help, that staff often told the resident they would return but did not always do so, and that multiple staff engaged in this behavior. Despite a request from surveyors, the facility did not provide additional resident interviews or information regarding this allegation by the end of the survey.
Failure to Complete Timely Baseline Care Plans for Wounds and Pain Management
Penalty
Summary
The deficiency involves the facility’s failure to complete timely and comprehensive baseline care plans that provided instructions for resident-centered care for three residents. One resident was admitted with multiple serious diagnoses, including acute kidney failure, anemia, atrial fibrillation, chronic respiratory failure, hypertension, a right femur fracture, morbid obesity, and muscle weakness. A nurse progress note documented a coccyx wound described as stage I open on the day of admission, yet no baseline care plan was initiated to direct staff in caring for the wound, managing pain, or addressing the resident’s chronic medical conditions. A care plan was not started until several days later, and when it was initiated, it only addressed advanced directives, oral/dental health problems, loneliness, and discharge planning, without including wound or pain management. Another resident was admitted with dysphagia, dementia, behaviors, a history of falls, and a urinary tract infection. Nursing progress notes documented skin issues on the buttocks, both heels, and the right knee, but the baseline care plan initiated the same day did not identify pressure wounds or any treatment for those wounds. A third resident, admitted after surgical repair of a lumbar 4 compression fracture, had a documented Stage 3 pressure ulcer and a lower back incision with intact staples on the admission nursing evaluation. However, the baseline care plan for this resident did not include wound management interventions or pain management for post-operative pain. During an interview, a staff member explained that the baseline care plan is triggered when the admitting nurse completes and locks the admission nursing assessment, and acknowledged that when assessments are not locked, baseline care plans are not completed and are not always done on time.
Failure to Honor Resident’s Right to Chosen Visitor
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to receive visitors of her choosing. A long-time friend of the resident, identified as NF1, reported that when she first attempted to visit the resident after the resident’s admission, staff member B escorted her out of the building and told her that law enforcement would be called if she returned. NF1 had previously been employed by the facility approximately four years earlier and had been terminated due to an allegation of abuse toward a resident. The facility did not allow her to visit the resident in any capacity. Another individual, NF2, stated he was aware that the facility was not allowing NF1 to visit the resident and that he knew about the prior abuse allegation but was not concerned about NF1 abusing the resident. NF2 stated he wanted NF1 to be allowed to visit and that the facility did not offer supervised visits or visits in a common area. He was hesitant to raise the visitation issue with the facility because he was concerned it might change how the resident was treated. Staff member B confirmed that any employee terminated due to an abuse allegation was not allowed to return to the building for any reason, and that this restriction was applied without considering the resident’s history with the visitor. The facility’s visitation policy stated residents have the right to receive visitors of their choice and that limitations may include denying or limiting access to individuals suspected of abuse until an investigation is completed or abuse is found, but the facility applied a blanket prohibition in this case.
Failure to Document and Investigate Resident Grievances Alleging Neglect and Inadequate Repositioning
Penalty
Summary
The deficiency involves the facility’s failure to follow its grievance policy and to ensure residents could voice grievances related to alleged abuse and neglect without discrimination or reprisal. One resident reported that a specific CNA (NF7) left his call light on for hours, did not assist with ADLs, and that this led to bowel and bladder incontinence while he waited for help at night. The resident stated that when the CNA finally responded, the CNA would force him to ambulate to the restroom instead of cleaning him in bed, and when the resident refused to ambulate, the CNA told him to sign a refusal of care form. The resident reported being afraid of this CNA and feeling neglected in his care, and he stated he reported these concerns to staff member C. An external email from NF6 to staff member C documented that the resident was afraid of NF7, described NF7’s statements about his job duties, and explicitly requested to file a grievance and have NF7 kept away from the resident. Additionally, a care conference note signed by staff member C documented the resident’s report of being made to sign refusal sheets at night and waiting 20–40 minutes for call lights to be answered. Despite this, staff member C, identified as the grievance official, stated there were no concerns brought forth from the resident or family regarding NF7, and no grievance was completed for this abuse/neglect allegation as required by the facility’s grievance policy. The deficiency also includes the facility’s failure to thoroughly investigate and document findings for another resident’s grievance regarding care. This resident, who had impaired mobility in both upper and lower extremities and was dependent for all ADLs except eating, reported that a night CNA was rough and refused to reposition his legs, and he stated he had complained to the facility but the issue continued. A written grievance from this resident documented that a male CNA would not readjust his legs for comfort. The grievance form’s investigative findings did not show any attempt to identify the specific night CNA involved or to clarify what care was being refused. Staff member E, who was responsible for investigating this grievance, could not recall details of the investigation and acknowledged she did not attempt to identify the accused CNA, characterizing the issue as a recurrent complaint and a miscommunication about repositioning due to the resident’s leg contractures. She stated she had encouraged the resident to be more specific about the repositioning requested but could not explain why this was not documented on the grievance form. The facility’s grievance policy required that grievances, including those involving abuse or neglect, be documented on a grievance form and investigated, but this was not done in accordance with policy for these residents’ complaints.
Failure to Timely Report Alleged Abuse and Neglect to State Agency
Penalty
Summary
The facility failed to timely report an allegation of abuse and neglect to the State Survey Agency involving one sampled resident, identified as resident #47. During an interview, resident #47 reported that a specific former staff member, NF7, would leave his call light on for hours, fail to assist with ADL care, and this lack of response resulted in the resident soiling his brief with bowel and bladder because he waited so long for help. The resident further stated that NF7 would encourage him to sign a refusal of care form and then expect him to ambulate to the restroom after he had already gone in his brief. In a separate interview, staff member B stated that no care concerns from the resident or family had been brought to their attention and acknowledged that they did not report the alleged abuse or neglect of care. A request by surveyors for documentation related to resident #47’s interdisciplinary team notes, any identified root causes, reporting, and investigation of concerns involving NF7 and resident #47 yielded no documentation by the end of the survey, demonstrating a lack of evidence that the allegation was reported or investigated as required.
Failure to Provide and Accurately Document ADL and Hygiene Assistance
Penalty
Summary
Surveyors identified that the facility failed to provide and accurately document assistance with activities of daily living (ADLs) for multiple residents. One resident, who was assessed on the MDS as dependent for all ADLs except eating (requiring only partial to moderate assistance with eating), reported not always receiving help with meals, having only sponge baths for several weeks instead of showers, and needing a shave while observed lying in bed in a hospital gown with several days of facial hair growth. This same resident had previously filed a grievance stating that a night nurse would not assist with use of a urinal despite his inability to do this himself, and that a male CNA would not readjust his legs for comfort. These findings showed a lack of consistent ADL assistance for a resident documented as dependent. Surveyors also found failures related to personal hygiene supplies and documentation for two other residents. One cognitively intact resident, dependent for oral hygiene and dressing, stated he had not been offered mouthwash or a warm washcloth to wash his face that day, and no mouthwash was present in his room; staff later confirmed they had never offered him mouthwash, despite documentation that personal hygiene was offered and that staff did most of the activity. Another resident, who stated she could wash her face, brush her teeth, and comb her hair mostly independently, reported that washcloths were never available unless she specifically asked staff, and on observation there were no washcloths in her room. Her EHR documentation showed staff did most of her personal hygiene activity, while staff later stated she was generally independent and that they had not been giving her a daily washcloth. These discrepancies demonstrated inaccurate ADL documentation and failure to routinely offer basic hygiene items such as washcloths and mouthwash.
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