Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Cooney Healthcare And Rehabilitation during CMS and state inspections, most recent first.
Two residents did not have their baseline care plans completed within 48 hours of admission, resulting in unmet ADL needs. One resident was encouraged to ambulate without required assistive devices, and another was found in bed in soiled clothing without access to a shower. Staff confirmed that baseline care plans were incomplete and did not reflect the residents' ADL requirements.
Two residents did not receive necessary ADL assistance: one was encouraged by staff to ambulate without required mobility aids against therapy recommendations, and another was left in bed and wet into the afternoon because staff did not provide morning care, citing the resident's sleepiness after a rough night.
Several residents experienced abuse, neglect, and deprivation of services, including being left in soiled briefs and bedding, not being assisted with toileting or repositioning, and being subjected to verbal abuse by staff. Some residents developed new wounds due to inadequate care, while others were left afraid to use their call lights. Staff failed to provide care according to professional standards, and multiple grievances were filed regarding rough and neglectful treatment.
The facility did not consistently follow its grievance process, resulting in multiple residents' complaints about care, mistreatment, and safety concerns being inadequately documented, investigated, or reported. Staff failed to complete required grievance forms, did not notify responsible parties, and in some cases, only documented actions after surveyor intervention. Several grievances involving alleged abuse, neglect, and poor staffing were not properly addressed or reported to the State Survey Agency.
A licensed nurse failed to meet professional standards by documenting treatments and assessments for multiple residents while not present in the facility, instead completing charting from home. Other staff confirmed the nurse was not onsite and did not provide the care documented. Facility policies prohibit falsification of records and require documentation to be based on first-hand knowledge, which was not followed in this case.
The facility did not maintain adequate nursing staff with the necessary skills to meet resident needs, resulting in multiple residents not receiving timely ADL care, toileting, and brief changes. Several residents were left in wet or soiled conditions overnight, and some were not assisted with transfers or toileting as required. Staff reported frequent call-offs, insufficient orientation for agency staff, and minimal management support during staffing shortages, leading to long call light response times and incomplete care.
A resident with dementia was moved between rooms twice without written notification to or consent from their representative, despite the representative's request to be present to assist. The lack of documentation and communication led to the resident experiencing frustration and anxiety during the moves.
A resident who fell while brushing his teeth was verbally abused by a nurse and CNA, who then removed his call light, water, and bedside table, and shut his door. The incident was reported by the resident's family and corroborated by staff, but the facility failed to investigate or report the alleged abuse to the State Survey Agency as required by policy.
A resident who was dependent on staff for toileting and at risk for pressure ulcers developed three new areas of moisture-associated skin damage after staff failed to provide timely incontinence care and did not follow the care plan. The resident reported being left in a wet brief overnight and staff expressed reluctance to use a Hoyer lift for changes, resulting in painful wounds.
Pressure ulcer care, wound monitoring, and repositioning failures led to in-house wound development and worsening for multiple residents. A new wound care nurse lacked prior experience and was unaware of a resident’s Stage II PU, while staff failed to notify the wound nurse of new wounds, follow wound orders, or document care accurately. One resident had a sacral wound with missed Triad application, another developed bilateral buttock wounds with incomplete orders, and a hospice resident’s sacral injury worsened to a Stage II PU with multiple new DTI areas amid poor repositioning and infection control lapses.
A resident with left wrist carpel tunnel reported unbearable pain rated 8/10 to 9/10, with visible swelling and worsening pain that moved up the arm and into the neck. The resident said Tylenol was not helping, while staff reported difficulty getting a timely response from the physician and no new pain orders were obtained during the period described. The resident was later sent for urgent x-rays, which showed no fracture, and returned with a wrist splint.
Failure to Supervise a Resident with Elopement History: A resident with a history of wandering and elopement left the facility unattended more than once and was later found after falling and sustaining minor injuries. Staff gave conflicting accounts of whether the resident was on 1:1 watch, 15-min checks, or both, and survey observations showed the assigned staff member was not consistently present while the check sheet documented otherwise. Staff also reported the front doors were not consistently secured or monitored, and the resident was not always accompanied by a sitter during observations.
Insufficient staffing led to delayed response to call lights, toileting, pain medication, and repositioning needs. A resident reported waiting up to 45 minutes for help and late pain meds, another resident reported repeated toileting delays and bowel movements in bed after CNAs did not return, and a third resident reported long waits for assistance and medication. Staff described weekend and night shifts as especially short, with only three CNAs covering multiple high-need residents and call lights and repositioning not consistently completed.
RN Coverage Not Provided Daily: The facility failed to ensure an RN was on duty for at least 8 consecutive hours a day, 7 days a week. PBJ staffing data and time punches showed multiple days with no RN hours reported, and an interview with staff member A could not confirm that the DON covered those shifts. The facility's census was above 60 residents, and its policy required 24-hour licensed nursing coverage and RN coverage for at least 8 consecutive hours daily.
Infection control was not followed during dirty laundry transport and wound care. A staff member moved a dirty laundry cart while touching multiple surfaces with soiled gloves and no hand hygiene, and an LPN performing wound care for three residents entered rooms without hand hygiene or EBP, touched carts, iPads, supplies, and room surfaces with dirty gloves, and did not consistently change gloves or use hand sanitizer between dirty and clean tasks.
Failure to implement an antibiotic stewardship program. Staff stated the facility did not currently have the program in place and had not provided staff training on it, with implementation planned after the next QAPI meeting. The facility policy stated the program was part of the infection prevention and control program and was intended to optimize infection treatment while reducing adverse events associated with antibiotic use.
Late MDS Submissions and Assessment Errors: The facility failed to submit MDS assessments within required timeframes. Review of the MDS dashboard showed numerous errors, including late MDS transmissions, late care plan signatures, late admission assessments, and resident information mismatches. Staff reported that resident mismatches were common and that the late submission issues were tied to a prior MDS coordinator who may not have known the 14-day deadline.
A facility failed to ensure a new wound care nurse had sufficient role-specific training before performing wound care duties. The nurse had no prior wound care experience or certifications, struggled to stage and classify wounds, and did not follow aseptic technique or EBP during dressing changes for two residents. The report also noted medication administration errors, including double doses of High Cal Med Pass, incorrect measurement of Voltaren Gel, and splitting Phospha 250 Neutral instead of using the ordered form.
Medication administration errors exceeded the allowed rate, with an 11% error rate found during survey observations and record review. An LPN gave double the ordered amount of High Cal Med Pass to two residents and measured Voltaren Gel using drams instead of grams, and another nurse cut Phospha 250 Neutral in half for a resident even though the medication information stated the tablet may need to be dissolved in water or swallowed whole.
Expired medications and supplies were found in the med storage room, including hydro gel, vancomycin injection bags, ipratropium bromide, COVID-19 test kits, Lovenox, timolol ophthalmic solution, bisacodyl suppositories, and latanoprost ophthalmic solution with no patient name. Wound vac supplies were also stored on the floor, and staff said they were unsure why the expired items were missed during weekly checks or why alcohol was not secured in a locked cupboard.
A resident with a suprapubic catheter was observed multiple times in the dining room and main lobby with the catheter drainage bag under his wheelchair, urine visible, and no dignity cover in place. An LPN stated the resident was care planned to refuse a dignity bag cover, but the care plan did not document that refusal, and the facility catheter care policy stated privacy bags would be available and drainage bags covered at all times while in use.
A resident with moderate cognitive impairment was involved in a potential sexual abuse investigation, but staff did not maintain effective controls to prevent further access during the investigation. Interviews showed the front doors were not routinely locked, visitor sign-in was inconsistently enforced because the receptionist had other duties, and survey observations found unlocked or propped-open entry doors with no alarm, allowing unmonitored access.
The facility failed to give a resident or the resident's representative written notice of the bed hold policy when the resident was transferred to the hospital, and it also failed to send all pertinent information to the receiving hospital. An staff member stated the notice and hospital report were not provided, even though facility policy required them.
A resident’s care plan was not updated to reflect symptomatic bradycardia, hospitalization, or heart monitor care. The resident had been hospitalized after heart rates dropped into the 40s, and staff later noted the monitor needed battery changes and symptom documentation, but the care plan and records did not include this cardiac information until after the issue was identified.
A resident who was normally continent of bowel and bladder experienced repeated bowel incontinence episodes because staff did not arrive in time to help him to the toilet. He reported that CNAs sometimes turned off his call light at night and did not return, leaving him in bed with bowel movements and feeling humiliated and frustrated. The care plan showed he needed moderate to substantial toileting assistance, and staff described severe night staffing shortages and delayed response to call lights.
A resident with a care plan noting potential altered hydration, dysphagia, impaired cognition, impaired vision, encephalopathy, and med side effects was repeatedly observed in bed without fluids or beverage containers within reach. Staff documented the resident often needed setup or supervision for eating and drinking, yet several observations showed no water pitcher, glass, or other beverages on the bedside table or nearby.
A resident received Seroquel for dementia, but the chart did not show behavioral notes or other documentation supporting the antipsychotic use. An RN stated the medication had been started in the hospital for nighttime delirium, while another staff member said they were not aware of nighttime behaviors and would need to check progress notes. The resident’s dementia diagnosis was listed without behavioral disturbance, psychotic disturbance, mood disturbance, or anxiety.
A resident was left waiting for a denture fitting appointment while missing her dentures and unable to eat her preferred foods. Staff said transport had been notified, but the appointment was missed after the clinic closure and no one rescheduled it when the clinic reopened. The facility policy stated it would assist with dental appointments and transportation when needed.
Delayed reporting of alleged sexual abuse: A visitor reported seeing what appeared to be sexual activity between a resident and her son, and the allegation was not reported to the State Survey Agency within the required 2-hour window. Staff cited conflicting stories, family requests, and uncertainty about the event, but the report was still submitted 25 hours after the incident occurred.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents. The environment contained hazards and lacked sufficient oversight, increasing the risk of incidents.
The facility did not consistently or thoroughly investigate and document four separate incidents involving resident injuries and concerns. Required interviews with involved residents, staff, and family members were not completed or documented, and root cause analyses were often missing. These deficiencies were attributed to changes in management and increased staff workload.
The facility did not ensure that all staff received proper education on resident transportation, maintain up-to-date yearly evaluations, or keep written job titles and duties in staff files. Some staff files lacked required documentation, and several employees reported confusion or lack of knowledge about transportation policies, especially newer staff. This resulted in staff feeling unprepared and unclear about their roles.
Two residents who used motorized wheelchairs did not have comprehensive, person-centered care plans addressing their needs for safe transportation to appointments. One resident's care plan lacked details on staff accompaniment and the need for verbal cues, despite an OT assessment indicating these were necessary, leading to a fall in the parking lot. Another resident's care plan did not reflect her preference for van transport or assess her safety using the wheelchair outside, even though she reported feeling unsafe with the current van setup.
A resident was injured and hospitalized after falling from a motorized wheelchair in the parking lot due to staff lacking proper competency and training in transportation procedures. Staff files showed missing evaluations, incomplete documentation of job roles, and no evidence of transportation-specific education prior to the incident.
The facility failed to supervise an LPN on probation, allowing her to perform duties beyond her scope without RN oversight, violating state regulations. Staff reported inadequate wound care and drug administration issues, contributing to a chaotic work environment and low staff morale.
An LPN at the facility performed wound care assessments and made recommendations without RN supervision, which was outside her scope of practice. This included assessing a resident's pressure ulcer independently. Interviews revealed that the LPN acted as a wound nurse and manager without proper oversight, highlighting a lack of awareness among staff about scope limitations.
The facility failed to report a potential abuse incident involving two residents to the State Survey Agency and the residents' representatives. One resident wandered into another's room and climbed into bed with him, but a staff member chose not to report it. The incident was discovered during a complaint investigation, revealing a failure to follow the facility's policy for reporting and investigating such incidents.
The facility's nursing staff failed to follow physician orders and complete wound treatments for two residents, leading to deficiencies in wound care management. One resident's records showed missed dressing changes and inconsistent documentation, while another resident's care involved improper aseptic techniques and incorrect dressing materials. These failures hindered accurate wound assessment and ongoing treatment needs.
The facility's inadequate staffing resulted in residents not receiving scheduled showers and experiencing long wait times for call light responses, leading to increased risks of dehydration and negative impacts on wound treatments. Residents reported feelings of embarrassment and discomfort, with some becoming incontinent while waiting for assistance. Staff interviews highlighted the challenges faced during understaffed shifts, and the facility's staffing data revealed a one-star quality rating and low weekend staffing.
The facility failed to label and date food items in the A-Hall refrigerator and did not maintain the walk-in freezer at the required temperature, leading to improperly stored food. Observations showed unlabeled and undated food items, and the freezer's temperature was above the required 0 degrees Fahrenheit, resulting in food not being frozen solid. This increased the risk of residents receiving contaminated food.
The facility failed to maintain proper infection control during a COVID-19 outbreak, with inadequate visitor screening, improper PPE use, and residents not wearing masks. A resident with COVID-19 was seen without a mask in common areas, and staff were confused about precautionary measures. Additionally, a wound dressing was not performed with aseptic technique, indicating broader issues in infection control practices.
The facility failed to accurately document DNR orders in the EHR and care plans for two residents. One resident's POLST indicated resuscitation, but the care plan and EHR showed a DNR status. Another resident's POLST also indicated resuscitation, yet the EHR and physician orders documented a DNR status, with no advance directive in the care plan. Staff interviews highlighted inconsistencies in managing and updating advance directives.
The facility failed to update care plans to reflect residents' preferences and needs for bathing and transfer methods. A resident's preference for bed baths was not documented, and two residents' care plans did not match the actual transfer methods used, potentially risking improper care.
A resident was dropped onto a bed during a transfer when staff used an incorrect Hoyer lift, which malfunctioned. The resident's care plan required a 700-pound capacity lift, but a smaller lift with a scale was used instead. The staff member was unfamiliar with the correct lift, which was stored elsewhere and appeared old.
A resident with severe cognitive impairment and a history of bowel obstruction was not provided sufficient hydration, as observed by dry lips and unaddressed requests for fluids. Despite a recommendation for 2,632 ml of daily fluid intake, the resident often had no fluids at the bedside, and staff did not consistently encourage hydration.
The facility did not ensure monthly medication regimen reviews were completed and documented for two residents. One resident had only one documented review with no irregularities, while another had missing reviews for specific months. A staff member confirmed that reviews were done monthly by the pharmacy but noted no staff were assigned to oversee their completion. Facility policy required reviews upon admission and monthly thereafter.
The facility failed to maintain a medication error rate below 5%, with errors observed in three residents' medication administration. Staff members did not verify physician orders with the MAR, leading to discrepancies and incorrect dosages being dispensed. Medication cards from other facilities were used without proper verification, contributing to the high error rate.
The facility did not ensure that the infection preventionist was certified before taking on the role. The staff member had only completed a portion of the required training modules and was aware of infection control issues upon hiring. The job description required certification in Infection Control and Epidemiology, which was not met.
Two residents experienced distress due to inaccessible call lights. One resident, on COVID-19 precautions, felt panicked when unable to reach the call light for hours, while another resident had to call out for help as her call light was hidden behind a recliner. Staff confirmed the importance of placing call lights within reach, as outlined in facility guidelines.
A resident admitted for rehabilitation and nursing care experienced a severe weight loss of 21.8% without nutritional interventions, inadequate pain management, and a lack of vital sign assessments as ordered by the physician. The resident's condition deteriorated, leading to a fall, sepsis diagnosis, and eventual death after transfer to the hospital. The facility's failure to address these issues resulted in an Immediate Jeopardy situation.
Failure to Complete Baseline Care Plans for ADL Needs Within 48 Hours of Admission
Penalty
Summary
The facility failed to ensure that baseline care plans were completed within 48 hours of admission to address the activities of daily living (ADL) needs for two residents. One resident reported being instructed by staff to ambulate without a walker or gait belt, despite not being cleared by therapy for such activity. The baseline care plan for this resident did not include necessary ADL care needs such as walking, toileting, transfers, bathing, or eating. Staff interviews confirmed that the resident should have used assistive devices per therapy evaluation, but this information was not communicated or documented in the baseline care plan. Another resident was found by a family member to be in bed, dressed in day clothes, soaked in urine, and unable to access a shower room. The baseline care plan for this resident also lacked documentation of ADL care needs, including walking, toileting, transfers, and bathing. Staff confirmed that the baseline care plans for both residents were incomplete and that the admitting nurse did not complete them at the time of admission.
Failure to Provide Required ADL Assistance to Dependent Residents
Penalty
Summary
The facility failed to provide appropriate assistance with activities of daily living (ADLs) for two dependent residents. One resident reported that a staff member instructed her to walk without her walker or gait belt over a weekend, despite not being cleared by therapy to do so. Staff interviews confirmed that the resident should have used a gait belt and four-wheeled walker for transfers and walking, as indicated by her therapy evaluation. The staff member who encouraged the resident to walk without these aids stated he was told during shift report that she did not need them. Another resident was found by family members wet and still in bed at 12:30 p.m., indicating that necessary ADL care had not been provided that morning. Staff documentation and interviews revealed that the resident was very sleepy and not waking up, and the staff member on duty allowed her to sleep, having been informed during shift report that the resident had a rough night. The staff member later expressed regret for not being more proactive in waking and toileting the resident.
Failure to Protect Residents from Abuse, Neglect, and Deprivation of Services
Penalty
Summary
Multiple residents experienced abuse, neglect, and deprivation of services due to staff actions and inactions. Several residents were left in urine-soaked briefs and bedding overnight, and some were not assisted with toileting or repositioning as required. One resident, who required a Hoyer lift for transfers, was not consistently checked or changed, resulting in three new areas of moisture-associated skin damage, including incontinence-associated dermatitis on both thighs and the intergluteal cleft. Another resident was left unclothed and soiled in bed after a CNA complained about having to change her, and was not assisted out of bed as needed. Residents reported being afraid to use their call lights due to staff behavior, and grievances were filed regarding rough and verbally abusive treatment by staff. Staff failed to provide care in accordance with professional standards, as evidenced by multiple grievances and facility-reported incidents. One resident was left on the commode for an extended period and had to return to bed without assistance. Another resident was not properly turned and repositioned, resulting in being found wet with urine and requiring a full bed linen change. There were also reports of staff yelling at residents, refusing to provide assistance, and being rough or mean during care. In one case, a resident who fell while attempting to brush his teeth was verbally abused by staff, who then removed his call light, water, and bedside table, leaving him unable to call for help. The facility received numerous grievances from residents and families regarding inadequate care, verbal abuse, and neglect. Staff interviews and documentation confirmed that several staff members, including agency and travel staff, were implicated in these incidents. In some cases, the abuse was not properly investigated or reported to the State Survey Agency. The Director of Nursing and other staff were made aware of these issues through incident reports, grievances, and direct observation, but the deficiencies persisted, affecting at least ten residents.
Failure to Operationalize and Follow Grievance Process
Penalty
Summary
The facility failed to ensure a comprehensive and effective grievance process for residents, resulting in multiple grievances being mishandled or inadequately addressed. Several residents and their representatives reported grievances related to room changes without notification or consent, safety concerns regarding unlocked doors, and lack of response to complaints. In some cases, staff did not complete required grievance forms or investigations, and documentation was either missing or completed only after surveyor requests, sometimes with backdated signatures. Specific incidents included a resident being left in bed naked and in soiled conditions overnight by a CNA, with no documented investigation or resolution provided to the resident. Another resident reported being yelled at and mistreated by a CNA, with the only documentation being a note that the resident felt safe after the CNA was no longer working at the facility. Additional grievances involved unacceptable staff-to-patient ratios, delayed care, and improper wound care, with documentation showing only minimal follow-up and some staff being reported to the State Survey Agency after the fact. There were also reports of a resident falling and subsequently being mistreated by staff, including having essential items removed from their reach and being yelled at. Multiple residents filed grievances about rough and mean treatment by a particular CNA, with at least ten residents affected. The facility's policy required thorough investigation, documentation, and reporting of grievances, especially those involving abuse or neglect, but these procedures were not consistently followed, and some grievances were not reported to the State Survey Agency as required.
Nurse Falsifies Medical Records While Offsite
Penalty
Summary
A licensed nurse, identified as staff member B, failed to uphold professional standards of nursing care by falsifying medical record documentation and health information for ten out of nineteen sampled residents. Staff member B documented treatments, assessments, and monitoring in the Treatment Administration Records (TARs) for multiple residents on a specific date, despite not being present in the facility to perform these tasks personally. This was confirmed through interviews with other staff members, who reported that staff member B was not in the building and instead completed charting from home, citing personal reasons for her absence. Record reviews revealed that staff member B charted a variety of nursing interventions and monitoring activities, such as skilled notes, wound care, medication monitoring, and behavioral assessments, for several residents. However, corresponding progress notes for these interventions were missing for the date in question, further supporting that the documented care was not actually provided by staff member B. Other staff members expressed concerns and suspicions about the accuracy of staff member B's documentation, with one nurse stating she was unable to complete her own charting due to staff member B's actions. The facility's employee handbook and documentation policy explicitly prohibit falsifying company records and require that documentation be factual, objective, and based on first-hand knowledge. Staff member B's actions were in direct violation of these policies, as she recorded information in the medical records without having performed the assessments or treatments herself. This resulted in inaccurate and misleading documentation for a significant number of residents.
Failure to Provide Sufficient Nursing Staff and Competent Care
Penalty
Summary
The facility failed to provide sufficient nursing staff with the appropriate competencies and skill sets to meet the needs of its residents, resulting in multiple instances where residents did not receive necessary activities of daily living (ADL) care and nursing services. Several residents reported being left in wet briefs overnight, not being checked or changed as required, and not receiving timely toileting assistance. In one case, a resident was left on the toilet for an extended period and had to return to bed without assistance. Another resident reported being left in bed naked and soiled with urine and feces overnight. These incidents were corroborated by interviews with residents and staff, as well as facility-reported incidents and grievances. Staff interviews revealed that the facility relied heavily on travel and agency staff, many of whom received little to no orientation or training specific to the facility. Staff reported that orientation for agency staff only occurred if a particular staff member was present, and no skills checklists were completed at the facility for these staff members. Agency staff themselves confirmed they had to learn the facility's routines and resident needs on their own, which hindered their ability to provide appropriate care. Additionally, staff reported frequent call-offs, particularly on nights and weekends, which led to inadequate staffing levels and long call light response times. Management rarely assisted by coming in to help cover shifts, further exacerbating the staffing shortages. Documentation reviews showed that a significant number of residents required two-person assistance for transfers and frequent checks and changes, which was difficult to accomplish with the available staff. On certain shifts, only one nurse was present for all LTC residents, and only three CNAs were available for five units, making it impossible to meet all residents' needs. The lack of staff also contributed to falsification of records, as one staff member completed required documentation from home rather than on-site. Multiple state survey agency incident reports confirmed that resident care was not being completed as required, and grievances were received regarding the lack of care provided.
Failure to Provide Written Notification of Room Change to Resident's Representative
Penalty
Summary
The facility failed to provide written notification to a resident's representative prior to making room changes, as required. The resident, who had dementia, was moved twice within a short period—once for rehabilitation and again for long-term care—without the representative being notified in writing or given the opportunity to be present. The representative had specifically requested notice to assist the resident during the move, but this request was not honored. No documentation or signed consent forms regarding the room changes were found in the resident's electronic health record (EHR), and there were no progress notes addressing the room changes or the resident's adjustment to them. During interviews, the resident's representative expressed anger and concern over the lack of notification, stating that the moves caused the resident frustration and anxiety due to his dementia. A staff member acknowledged that she did not obtain written consent, mistakenly believing an email from the representative was sufficient, though the email only requested discussion about the move and did not provide consent. This oversight resulted in the resident being moved without proper notification or support from his representative.
Failure to Investigate and Report Alleged Verbal Abuse
Penalty
Summary
The facility failed to investigate and report an allegation of verbal abuse involving a resident who experienced a fall while attempting to brush his teeth. After the fall, the resident and his family reported that a nurse and CNA yelled at him for self-transferring, removed his call light, water, and bedside table, and shut his door, preventing him from seeking further assistance. Multiple staff statements corroborated that the nurse and CNA verbally abused the resident and took away his means to call for help, with one staff member noting that the doors were closed for all residents at risk of falling. The incident was reported by the resident's family through grievance forms, which were received by staff and reportedly forwarded to the appropriate administrator. Despite facility policy requiring all alleged violations of abuse to be reported to the Administrator and State Survey Agency within specified timeframes, the administrator stated he had no knowledge of the incident or grievances. The abuse was not reported to the State Survey Agency as required, and no Facility Reported Incident was submitted until the surveyor brought the matter to the administrator's attention. Review of the reporting portal confirmed that the required report was not made in a timely manner.
Failure to Provide Incontinence Care Results in Moisture-Associated Skin Damage
Penalty
Summary
Staff failed to provide care in accordance with a resident's comprehensive person-centered care plan and the resident's expressed preferences, resulting in the development of three new areas of moisture-associated skin damage. The resident, who was at risk for pressure ulcers and dependent on staff for toileting and incontinence care, reported that over a weekend, CNAs did not consistently perform check and changes as needed. The resident stated that staff complained about the time and effort required to use a Hoyer lift for brief changes and left her in a wet brief overnight. Another resident corroborated that staff refused to change the resident's brief, citing it was only damp and that using the Hoyer lift was too much work. Review of the resident's records showed that prior to the incident, there was no skin breakdown on her medial thighs or intergluteal cleft. However, following the period of inadequate care, three new areas of incontinence-associated dermatitis were documented, all described as painful and burning by the resident. The care plan required thorough skin care after incontinent episodes and the use of barrier cream, as well as assistance with toileting upon request. Despite these interventions being in place, staff did not follow the care plan, leading to the resident acquiring new wounds.
Pressure ulcer care, wound monitoring, and repositioning failures
Penalty
Summary
Pressure ulcer care was not provided consistently, and several residents had wounds that were not identified, monitored, treated, or prevented from worsening. The report states that the facility failed to ensure pressure ulcer wounds were identified, closely monitored, treated, and prevented from developing or worsening, and that wound care was not completed per physician orders. It also states the wound care nurse was not informed of new wounds, infection control practices were not followed during wound care, and licensed nursing staff documented wound care as completed when it was not done. Staff member F stated they were new to the wound care role, had no prior wound care experience, and were not yet certified as a wound care nurse. Staff member F also stated they were unaware of a Stage II pressure ulcer on resident #9 and would not have known about it if the surveyor had not notified them. Staff member F described the wound notification process as incomplete and said staff sometimes told them directly, texted them, or used a box outside the administration office, but that many staff did not yet know who they were. The report also states that the floor nurse who discovered resident #9's wound should have notified administrative staff or the wound care nurse and obtained physician orders. Resident #2 had a Stage II wound that developed in-house, and during wound care observation the prior dressing was not signed or dated and there was no residual Triad ointment on the skin, which staff member F stated indicated the previous nurse did not follow the physician's orders. Resident #6 had wounds on both buttocks; staff member F stated the wound on the left buttock was new and had not been open the last time it was observed, and the physician order only addressed redness on the right buttock with Triad cream. Resident #8, who was on hospice and fully dependent for repositioning and skin care, had a Stage I sacral pressure injury that worsened to a Stage II pressure ulcer with six new deep tissue injuries on the buttocks. The report states resident #8 repeatedly lay on her back without pillows or positioning devices, repositioning documentation was incomplete, bilateral ear dressings were documented as completed even though they were still dated from a prior change, and during wound care staff member F touched the iPad, Healx stickers, and clean supplies with soiled gloves without hand hygiene. The report also states resident #8's skin breakdown was due to pressure and lack of repositioning, and that residents #2, #6, and #8 had in-house acquired wounds.
Delayed Pain Management for Severe Wrist Pain
Penalty
Summary
The facility failed to ensure timely pain management for a resident who was experiencing severe left wrist pain. During observation, the resident was found lying in bed holding the left wrist, wincing in pain, and stated the pain was 8/10 and later 9/10, describing it as unbearable. The resident reported having carpel tunnel in the left wrist, said Tylenol was not helping, and stated the nurse was aware of the pain. The resident also reported receiving oxycodone twice a day for peripheral neuropathy, but no effective pain relief was documented for the wrist pain during the period described. Staff member F stated the resident had been in pain for the last couple of days and that the physician was contacted without receiving a response. She stated she contacted the physician's office again the next morning and was told the resident would be seen several days later, with no new orders given for pain management. The resident was later sent for urgent care x-rays of the wrist, which showed no fractures, and returned with a wrist splint. The resident's care plan dated 8/13/25 did not reflect wrist pain or carpel tunnel, and the facility's pain management policy stated that pain management must be provided consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences.
Failure to Supervise a Resident with Elopement History
Penalty
Summary
The facility failed to ensure a resident who had a history of elopement was monitored and supervised sufficiently to prevent leaving the building unattended. Resident #6 had documented episodes in which he left the facility without staff knowledge, including one event in which he was found walking in the parking lot with a small laceration to his index finger and another event in which he was later found after being missing from the dining room. During the later incident, the resident fell, sustained a scrape to his right forearm, reported right hip pain, and was sent for an x-ray to rule out a broken hip. Records and staff interviews showed inconsistent and unclear supervision practices for the resident. Staff described the resident as being on 1:1 observation, 15-minute checks, or both, but staff members gave conflicting explanations about how those interventions were supposed to work. One staff member stated the resident was on 1:1 watch because of prior elopement, while another stated the resident was on 15-minute checks unless he was showing behaviors or exit seeking, at which time he would be on 1:1. During survey observations, the assigned staff member was not in the resident’s room for periods longer than the documented 15-minute checks, and the check sheet did not match what was observed. Staff also described the facility’s front doors as unlocked at times and stated the doors were not consistently monitored. One staff member said the doors were never locked until the night of the survey observation, while another said the doors were locked to prevent entry but not exit. Staff further stated the resident had eloped twice, that the first event in the parking lot was not considered an elopement by the facility, and that the resident had been found about 1.1 miles away during the later event. Multiple staff members acknowledged that the resident wandered, that the facility had staffing limitations at night, and that the resident was not consistently accompanied by a sitter during survey observations.
Insufficient Staffing and Delayed Resident Assistance
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet resident needs for 3 of 26 sampled residents. Resident #2 reported that staffing could be so short that she waited up to 45 minutes for help, sometimes went to the restroom without staff because she could not wait any longer, and stated that pain medications were late, call lights were not answered at night or on weekends, and her sheets had not been changed in weeks. Resident #54 also stated the facility was short handed, that she sometimes waited a long time for help, and that pain medication could take as long as an hour to be brought to her. Resident #11 stated he had several incontinence episodes because staff did not assist him to the toilet in a timely manner, including times when CNAs turned off his call light at night and said they would return but did not, resulting in bowel movements in his bed. His care plan reflected that he required moderate to substantial assistance with toileting, and he stated the delays were humiliating and frustrating. Staff interviews supported the residents’ reports, with multiple staff stating weekend and night staffing was poor, call lights were not consistently answered, residents were not being repositioned, and there were only three CNAs on nights to care for residents including dementia residents, two-person Hoyer residents, and elopers.
RN Coverage Not Provided Daily
Penalty
Summary
The facility failed to ensure a registered nurse was on duty for at least eight consecutive hours a day, seven days a week. Review of the facility's CASPER PBJ Staffing Data Report for 1/1/25-3/31/25 showed no registered nursing hours on multiple dates, including 1/4/25, 1/5/25, 1/19/25, 1/25/25, 1/26/25, 2/15/25, 2/16/25, 3/2/25, 3/9/25, 3/15/25, 3/16/25, 3/22/25, and 3/23/25. Facility time punches reviewed for those dates matched the PBJ report. During an interview on 9/10/25, staff member A stated he thought the DON may have covered the shifts in question, but he no longer worked at the facility and could not confirm that the DON worked those shifts. The facility's Census vs Budget for April 2025 through June 2025 showed an average daily census of 66.76, and the facility policy stated that licensed nursing staff must be provided 24 hours a day and that an RN must be used for at least 8 consecutive hours a day, 7 days a week.
Infection Control Failures During Laundry Transport and Wound Care
Penalty
Summary
The facility failed to ensure infection control measures were followed during the transport of dirty laundry. During an observation, a staff member rolled a dirty laundry cart from the laundry room on the first floor to the basement while touching three different doorknobs and one push-button door code with the same soiled gloves and without performing hand hygiene. The staff member stated it was hard to transport dirty laundry to the basement because the elevator had been broken since October 2024 and said she did not know when it would be fixed. She also stated, "We need to improve our infection control; I don't like that my dirty gloves are touching everything. We should be better." Other staff later stated she had raised concerns about transporting dirty linens with hand hygiene and compliance. The facility also failed to ensure enhanced barrier precautions and aseptic technique were followed during wound dressing changes for three residents. During wound care for one resident, a staff member entered the room without hand hygiene or gown and gloves, brought the wound cart into the room, touched the wound care iPad, cart drawers, supplies, and packaging with soiled gloves, and then used those same supplies to complete the dressing change. During wound care for a second resident, the staff member again entered without hand hygiene or enhanced barrier precautions and touched the overhead light, iPad, stickers, adhesive remover, and wound supplies with dirty gloves. During wound care for a third resident with wounds to the sacrum, right knee, right great toe, and right ankle, the staff member changed gloves between some tasks but did not use hand sanitizer between glove changes and did not change gloves between dirty and clean tasks. The staff member stated she had not thought about changing gloves when all the wound care was for the same resident and said she had not had formal training on wound care.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement and educate staff on an antibiotic stewardship program as part of its infection prevention and control program. During an interview on 9/11/25 at 8:03 a.m., staff members B, C, and D stated that the facility did not currently have an antibiotic stewardship program implemented and did not provide training on the program to staff. They also stated that the program would be put in place after the next QAPI meeting, scheduled for 9/23/25. Review of the facility policy, titled Antibiotic Stewardship Program and revised 4/9/25, stated that it was the facility's policy to implement an antibiotic stewardship program to optimize the treatment of infections while reducing adverse events associated with antibiotic use.
Late MDS Submissions and Assessment Errors
Penalty
Summary
The facility failed to ensure MDS assessments were submitted within the required timeframe after assessment. Review of the MDS error dashboard for submission dates 1/1/25 through 9/8/25 showed that, of 604 assessments counted, 190 had errors. The errors included late MDS transmissions, late care plans for CAA signatures, late admission assessments, and resident information mismatches. Monthly error counts included 16 errors in one month, 11 errors in another month, 28 errors in March 2025, 33 errors in April 2025, no assessments submitted in May 2025, 28 errors in June 2025, 21 errors in July 2025, and three errors in August 2025. During observation and interview on 9/10/25, the MDS dashboard showed no late indicators, and staff member HH stated that late MDSs would trigger many other alerts, resident mismatches were common due to issues such as missing middle initials or discrepancies from previous facilities, and the late submission issues were from the previous MDS coordinator who had left in July and may not have known about the 14-day submission deadline.
Inadequate wound care nurse training and medication administration errors
Penalty
Summary
The facility failed to ensure staff member F had the appropriate and sufficient education before starting a wound care nurse position. Staff member F stated the position was new, that they had no prior wound care experience or wound care certifications, and that their duties included weekly wound evaluations, wound measurements, identifying wound types, staging wounds, and determining wound treatments. During interview and observation, staff member F said it was sometimes difficult to classify wound severity because they were new to the role and repeatedly asked the surveyor for help staging and classifying wounds while performing wound care observations. During wound dressing changes for two residents with wounds, staff member F did not follow aseptic technique or enhanced barrier precautions. For one resident, staff member F entered the room without gown or gloves, brought the wound care cart into the room without cleaning it afterward, and touched multiple surfaces with soiled gloves after removing a dirty dressing. For another resident with a wound on the right ear, staff member F removed the dirty dressing and then touched the overhead light, the wound care iPad, Healx stickers, and items in the wound care cart. The facility’s competency records showed generalized nursing competencies, including weekly head-to-toe wound competencies, but did not show education specific to the wound care nurse position and its duties. The report also documented medication administration errors by other staff, including giving double the ordered amount of High Cal Med Pass to two residents, measuring Voltaren Gel incorrectly, and cutting Phospha 250 Neutral in half instead of using the ordered form or dissolving it.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to keep the medication error rate below 5 percent, with surveyors determining an 11 percent error rate based on observations, interviews, and record review. During a medication pass for resident #32, staff member G administered 120 mL of High Cal Med Pass when the order was for 60 mL, and also prepared Voltaren Gel by squeezing approximately two drams into a medicine cup even though the medication was ordered in grams. Staff member G later stated she did not have a way to measure grams of the gel and used the drams measurement on the medicine cups instead. During another observation, staff member G again administered 120 mL of High Cal Med Pass to resident #12 when the order was for 60 mL. In interview, staff member G stated she later found the measuring tool for the Voltaren gel, asked a nurse how to measure the High Cal Med Pass, and learned she should have measured two 30 mL cups to equal the 60 mL order; she also stated she was now aware she had been giving double the ordered amount for several residents and that drams did not equal grams. For resident #27, staff member L cut Phospha 250 Neutral in half and administered it that way, even though the resident’s order allowed meds to be crushed or capsules opened as needed unless contraindicated, and the medication information stated the tablet form may need to be dissolved in water or swallowed whole.
Expired medications and unsecured storage in medication room
Penalty
Summary
Medications and biologicals stored for use were found expired in the medication storage room during an observation and interview with staff member B. Items identified included hydro gel expired 3/2025, multiple vancomycin injection fluid bags with expiration dates of 12/2024, 11/2024, 1/2025, 6/2025, and 2/2025, a box of ipratropium bromide expired 5/2025, COVID-19 test kits expired 1/18/24, Lovenox expired 8/2025, timolol ophthalmic solution expired 1/2025, bisacodyl suppositories expired 1/2025, and latanoprost ophthalmic solution expired 12/2024 with no patient name. Wound vac supplies were also stored on the floor in four boxes. Staff member B stated she was not sure why the medications were missed during the weekly checks or why alcohol was not secured in a locked cupboard. Staff member M stated she reviewed the medication rooms for expired medications weekly. The facility policy dated 6/25/25 stated medication rooms and carts would be inspected periodically for expired medications and nurses would observe expiration dates prior to administration.
Catheter drainage bag left uncovered in public areas
Penalty
Summary
The facility failed to ensure that resident catheter bags were covered in public areas for 1 of 2 sampled residents with catheters, resident #25. During observations on 9/8/25 at 2:53 p.m., 9/9/25 at 8:00 a.m., and 9/10/25 at 12:20 p.m., resident #25 was seen in the dining room and main lobby socializing or eating breakfast with his catheter bag under his wheelchair, urine visible in the bag, and no dignity cover in place. During an interview on 9/11/25 at 3:00 p.m., staff member C stated the resident was care planned to not have a dignity bag cover because he would refuse. However, review of resident #25's care plan, initiated 3/5/24, did not show refusal of a dignity bag cover under the focus area of the suprapubic catheter. The facility policy, Catheter Care, dated 5/2/25, stated that privacy bags would be available and catheter drainage bags would be covered at all times while in use.
Failure to Secure Entry During Abuse Investigation
Penalty
Summary
The facility failed to put effective measures in place to prevent further potential abuse while an investigation was in process for one resident with a BIMS score of 9 and moderate cognitive impairment. The State Survey Agency received a report of potential sexual abuse involving the resident, but staff described ongoing difficulty controlling access to the building, especially at night, and stated the front doors were not routinely locked. One staff member said it was harder at night to prevent the resident’s son from coming in, while another stated the front doors were never locked or expected to be locked until that night. Staff interviews showed the visitor sign-in process was not consistently enforced because the receptionist had other duties and was not always at the desk. The office assistant stated she could not control every visitor and sometimes had to leave the desk for other tasks or to use the bathroom. Supervisory staff acknowledged the need for coverage at the front desk but could not identify alternative solutions. Survey observations also found the front doors unlocked on one evening, and later found the front door locked but the rehabilitation doors propped open and unlocked with no alarm, allowing entry and exit without detection. The facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, stated residents should be protected from any further harm during investigations.
Failure to Provide Transfer Notice, Bed Hold Information, and Hospital Report
Penalty
Summary
The facility failed to notify resident #5 or the resident's representative in writing of the facility's bed hold policy when the resident was transferred to the hospital, and it also failed to provide all pertinent information to the receiving hospital. During interview, staff member C stated the facility did not provide a notice of transfer or bed hold to resident #5 or the resident's representative and was not able to produce documentation showing that the receiving hospital received a report with all pertinent information for resident #5. Staff member C stated these items should have been provided according to facility policy and were not.
Care Plan Not Updated for Cardiac Monitoring Needs
Penalty
Summary
The facility failed to ensure resident care plans were updated with relevant care information for resident #4. During observation, the resident was lying in bed and pointed to a small heart monitor on his chest, stating he had been hospitalized for his heart rate and that there had been discussion about needing a pacemaker. Hospital records showed the resident experienced symptomatic bradycardia with heart rates into the 40s while at the facility, which resulted in hospitalization and an ICU stay. However, the resident’s care plan, last reviewed on 5/28/25, did not include information about the bradycardia or heart monitor care. Staff later stated the cardiac monitor was blinking and batteries needed to be changed, and that another nurse had shown how to change the batteries and document symptoms and monitor settings, but this information was not listed on the medication or treatment records. A staff member also stated the prior DON had not completed a progress note or care plan update related to the resident’s cardiac status and heart monitor.
Delayed Toileting Assistance Led to Bowel Incontinence
Penalty
Summary
The facility failed to ensure that a resident who was incontinent of bowel received appropriate services to restore as much normal bowel function as possible for 1 of 26 sampled residents. Resident #11 stated that since admission he had several incontinence incidents because staff did not arrive in time to help him get to the toilet. He reported that during the night CNAs would come in, turn off his call light, say they would return to assist him, and then not return, which resulted in bowel movements in his bed. He stated it often took more than 30 minutes to receive help when he needed to use the toilet, and that he was normally continent of both bowel and bladder but found the episodes humiliating and frustrating. The resident’s care plan, dated 8/13/25, reflected that he required moderate to substantial assistance with toileting. Staff member F stated she had heard from the resident and his wife that he had a few bowel movements in his bed on night shifts, while day shift did not have trouble meeting his call light needs and he had not had bowel movements in his bed during day shifts. Staff member F stated the resident was continent of bowel and bladder so long as he had assistance to the toilet. Other staff members described severe night staffing shortages, with only three CNAs for multiple dementia residents and multiple two-person Hoyer residents, and stated call lights were not always answered promptly. One staff member stated staffing was not safe, the float nurse often left early, management rarely came in to help, and repositioning often did not get done.
Fluids Not Readily Available for Resident With Hydration Risk
Penalty
Summary
The facility failed to ensure resident #55 had fluids readily available. During observations on 9/8/25, 9/9/25, and 9/10/25, resident #55 was found in bed without beverages or beverage containers within reach, including an empty table in front of him, no water pitcher or glass on the table, an old coffee mug with dried residue out of reach, and no fluids on either bedside table. On 9/11/25, resident #55 was observed in bed with a glass of water and a straw by his bedside, and staff member T stated the resident was capable of drinking from a glass on his own. The care plan identified resident #55 as having the potential for altered hydration related to decline, dysphagia, impaired cognition, impaired vision, encephalopathy, and medication side effects, with interventions to encourage food and fluid intake. The resident also had an ADL self-care deficit with eating assistance listed as 1 person extensive assistance, and eating and drinking task documentation from 8/13/25 through 9/10/25 showed the resident was often documented as needing setup or clean up assist, with some supervision/touching assist, and was independent only four times.
Psychotropic Medication Used Without Supporting Behavioral Documentation
Penalty
Summary
The facility failed to ensure that psychotropic medication use was supported by appropriate diagnoses and behavioral monitoring for one resident. Resident #72 received 25 mg of Seroquel, an antipsychotic, for a diagnosis of dementia, but the medical record from 9/5/25 to the current review did not contain behavioral notes or other documentation showing a reason for the medication. During interview, NF2 stated the resident had been started on Seroquel in the hospital because of some nighttime delirium. Staff member BB stated they had not heard of the resident having nighttime behaviors and would need to check progress notes. NF8 stated that medication appropriateness review would include diagnoses, progress notes for behaviors, and clarification regarding the dementia diagnosis, which was listed as dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety.
Failure to Arrange Denture Appointment and Transportation
Penalty
Summary
The facility failed to assist a resident with making and arranging transportation for a denture appointment, despite the resident stating she had been waiting a long time for the appointment and was missing her dentures. During observation and interview, the resident said she could not eat the foods she preferred because she did not have her dentures and had been told the facility was scheduling the appointment when she was admitted, but she had not heard anything since. Staff later stated that transport had been told about the denture appointment two weeks earlier, that the dentures had already been paid for, and that the resident only needed to go to the denture clinic for fittings. When staff contacted transportation during the interview, they were told the appointment had fallen through the cracks because the denture clinic had been closed for a week and no one had called to reschedule after reopening. The facility policy stated it would assist residents, if necessary or requested, with making dental appointments and arranging transportation to and from dental services.
Delayed reporting of alleged sexual abuse
Penalty
Summary
The facility failed to report an alleged sexual abuse incident to the State Survey Agency within the required two-hour timeframe for one resident. A visitor reported that while entering the resident’s room, she observed what appeared to be sexual activity between the resident and a man she initially thought might be the resident’s husband. She stated the resident appeared shocked, the man was standing up from a wheelchair despite being a double amputee, and the resident’s hand was near the man’s groin. The visitor reported the incident to a staff member after waiting in the hallway for about 30 minutes, then left the facility and later learned the man was the resident’s son. During interview, staff stated the facility’s policy was to report such incidents within two hours, but the report to the State Survey Agency was time-stamped at 10:45 a.m. on 9/4/25, which was 25 hours after the incident occurred. Staff gave several reasons for the delay, including conflicting stories, the family’s request not to report, not knowing the son was a registered sex offender, the resident being pleasant and in no distress, the allegation being vague, and the daughter having already asked the son to leave the facility. The facility policy reviewed stated that allegations must be investigated and reported within federal timeframes.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to accidents, and that supervision was not sufficient to prevent such incidents. Specific actions or inactions leading to this deficiency include the presence of hazards and a lack of appropriate oversight in the area in question. No additional details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Thoroughly Investigate and Document Facility Reported Incidents
Penalty
Summary
The facility failed to fully investigate and document four Facility Reported Incidents (FRIs) involving resident injuries and concerns. In one case, a resident sustained a fracture, but the investigation did not include interviews with the injured resident, relevant staff, or resident representatives, nor was a root cause analysis documented. Another incident involved an unwitnessed fall resulting in a hospital visit; while the interdisciplinary team identified a root cause, there was no documentation of interviews with the resident or staff involved. In a third case, a family member expressed concern and requested hospital transfer for a resident, but the investigation only included a nurse interview and omitted interviews with the resident, family member, CNA, or other involved staff, and lacked a root cause analysis. The fourth incident involved a resident who fell in the facility's parking lot, was hospitalized, and later died; the investigation did not include interviews with the resident or key staff, and there was no documentation of potential root causes. The facility's policy required thorough investigation and documentation of incidents, including root cause analysis and interviews with witnesses and involved parties. However, the investigations reviewed were inconsistent and incomplete, lacking required interviews and documentation. Staff attributed these deficiencies to changes in upper management and increased workload, resulting in incomplete investigations for all four reviewed incidents.
Deficient Staff Training and Documentation for Resident Transportation
Penalty
Summary
The facility failed to ensure that new and existing staff were properly educated regarding the transportation of residents, that yearly evaluations were completed and documented, and that written job titles and duties were maintained in staff files. Interviews revealed that onboarding trainings, job titles, and job duties were expected to be in staff files, but clinical trainings were kept separately. Review of staff files showed missing or incomplete onboarding documentation, with some documents unsigned or undated. One staff member's file lacked yearly evaluations, job title, job duties, and a driver's license, and there was no evidence of education related to their specific job role. The facility's policy required documentation of necessary training and licensure for staff authorized to drive the facility van, but this documentation was not consistently present. Staff interviews indicated that some employees had not received transportation education prior to a recent incident involving a resident, and others could not recall when they last received such training. Some staff expressed confusion about the new transportation policy or were unaware of it altogether, particularly newer employees. The lack of consistent and documented training, evaluations, and clear job descriptions contributed to staff feeling unprepared and uncertain about their roles and responsibilities regarding resident transportation.
Failure to Develop Comprehensive Care Plans for Residents Using Motorized Wheelchairs
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents who used motorized wheelchairs, resulting in unmet needs and safety concerns. For one resident, the care plan did not specify whether she could leave the building for appointments using her motorized wheelchair, nor did it indicate if staff accompaniment was required or which staff should be responsible. Additionally, the care plan did not address the need for verbal cues for safety, as identified in the occupational therapy assessment, which stated the resident required close supervision and verbal cues when outside the facility. This lack of detailed planning contributed to an incident where the resident fell in the parking lot while using her motorized wheelchair outside the facility. For the second resident, the care plan only noted the use of an electric wheelchair for locomotion within the facility and did not document her preference for using the facility van for appointments or assess her safety when using the motorized wheelchair outside. The resident expressed discomfort and a sense of unsafety when using a borrowed van with a manual lift, but this was not reflected in her care plan. The facility's policy requires comprehensive care plans with measurable objectives and clear staff responsibilities, but these requirements were not met for either resident.
Failure to Ensure Staff Competency in Resident Transportation
Penalty
Summary
The facility failed to ensure that nurses and nurse aides possessed the appropriate competencies to safely care for residents, specifically regarding transportation services outside the facility. Staff files lacked documentation of yearly evaluations, demonstration of skills, review of adverse events, and evidence of competency in activities within their scope of practice. One staff member's file did not include a job title, job duties, or education related to their specific role, and their yearly education consisted mainly of computer-based training without assessment of critical thinking or ability to manage care in complex environments. Interviews revealed that the facility did not provide transportation education to staff prior to the incident, and staff could not recall when such training last occurred. As a result of these deficiencies, a resident was not safely assisted during transportation services, leading to a fall in the parking lot and ejection from their motorized wheelchair. This incident resulted in the resident being transferred to the hospital. The lack of staff competency and training in transportation procedures directly contributed to the resident's injury and subsequent hospitalization.
Failure to Supervise LPN on Probation and Ensure Competent Nursing Staff
Penalty
Summary
The facility failed to provide adequate oversight to ensure that the nursing scope of practice was being followed, particularly concerning staff member C, an LPN whose license was on probation. Staff member C was involved in multiple roles, including wound care specialist, without the required supervision from an RN or other authorized personnel. This lack of supervision was in direct violation of the Montana Code Annotated, which mandates that LPNs perform their duties under the supervision of a registered nurse or other qualified healthcare provider. Interviews with staff members F and H revealed concerns about the quality of care provided to residents, including incidents where staff were instructed to move a resident who had fallen without first checking vital signs or using appropriate equipment. Staff member C's probationary status required direct supervision and regular reporting to the Board of Nursing, conditions that were not met. Staff member H reported that staff member C was aggressive and involved in administering narcotics without supervision, and there were instances of drug diversion. Additionally, staff member C was responsible for wound care without proper oversight, leading to inadequate wound management as described by staff member H. The facility lacked a current job description for staff member C's role, and there was no evidence of ongoing verification of professional licenses after initial hiring. The facility's administration was unaware of the restrictions on staff member C's license and failed to ensure compliance with the probationary terms set by the Board of Nursing. Staff member G admitted to not knowing who was responsible for submitting the required quarterly reports to the Board. This oversight contributed to a chaotic work environment, as described by staff members, with low morale and concerns about resident neglect. The facility's failure to uphold disciplinary actions and ensure proper supervision of staff member C resulted in a deficiency in maintaining competent nursing staff.
LPN Exceeded Scope of Practice in Wound Care
Penalty
Summary
The facility failed to ensure that staff were performing care within their scope of practice and with the necessary training, specifically involving a Licensed Practical Nurse (LPN) identified as staff member C. Staff member C was reported to have performed duties as a wound specialist, including making determinations and recommendations about a resident's wound without the supervision of a Registered Nurse (RN). This was confirmed through interviews with other staff members who stated that staff member C had been functioning in roles such as a wound nurse, floor nurse, manager, and scheduler without RN oversight. The deficiency was highlighted by the case of a resident with a left ear pressure ulcer, where staff member C independently completed a wound assessment, which was outside the scope of practice for an LPN according to the Montana Code Annotated. The report further detailed that staff member C's actions included assessing, evaluating, planning, and implementing resident care plans related to wound care, which should have been performed under the supervision of an RN or other authorized medical professional. Interviews with other staff members revealed a lack of awareness regarding the limitations of an LPN's scope of practice, indicating a systemic issue within the facility's training and supervision protocols. This oversight increased the risk of negative outcomes for residents receiving care from staff member C.
Failure to Report Potential Abuse Incident
Penalty
Summary
The facility failed to report an incident of potential abuse involving two residents to the State Survey Agency and the residents' representatives. The incident involved one resident wandering into another resident's room and climbing into bed with him, which was not reported by a staff member who deemed it too much work. This lack of reporting was discovered during a complaint investigation, and it was found that the facility did not follow its policy for reporting and investigating such incidents. The residents involved were both confused, with one resident displaying overly attentive behavior towards males. The facility's policy required immediate reporting of such incidents to the state licensing agency, but this was not done. Interviews with staff and family members revealed that the incident was not communicated to the appropriate parties, leading to a delay in addressing the situation and implementing preventive measures.
Deficiencies in Wound Care Management
Penalty
Summary
The facility's licensed nursing staff failed to adhere to physician wound care orders and complete necessary wound treatments for two residents, leading to deficiencies in wound care management. For one resident, the electronic health record (EHR) showed an increasing wound size over time, with missed documentation in the Weekly Wound Reviews and missed dressing changes. The resident's medication administration record (MAR) indicated missed dressing changes on specific dates, and clinic reports noted the resident arrived without prescribed dressings multiple times. The Weekly Wound Review documentation revealed inconsistencies in wound staging and measurements, with some entries left blank. For another resident, the EHR documentation lacked specificity in wound location, measurements, and characteristics, with discrepancies between weekly assessments. Observations showed improper aseptic techniques during dressing changes, such as not changing gloves between handling dirty and clean dressings. Additionally, the staff failed to follow physician orders for wound dressing materials, using incorrect items and not labeling dressings with initials, dates, or times as required by facility policy. These failures in wound care management made it challenging to accurately assess the status, location, and severity of the wounds, hindering ongoing treatment and care needs. The lack of adherence to physician orders and facility policies contributed to the deficiencies observed during the survey, impacting the quality of care provided to the residents with wounds.
Inadequate Staffing Leads to Resident Care Deficiencies
Penalty
Summary
The facility failed to provide adequate staffing, resulting in several deficiencies in resident care. Observations, interviews, and record reviews revealed that residents did not receive scheduled showers, and call lights were not answered promptly. Specifically, one resident did not receive scheduled showers, and five residents experienced long wait times for call light responses, sometimes up to 45 minutes. This inadequate staffing led to increased risks of dehydration and negatively impacted wound treatments and services. Residents expressed feelings of embarrassment and discomfort due to missed showers and long wait times, with some residents becoming incontinent while waiting for assistance. Interviews with residents and staff highlighted the facility's staffing issues, particularly during night shifts and when the facility was short-staffed. Staff members reported that when fully staffed, the unit ran smoothly, but when understaffed, it became stressful, and tasks such as showers and lifts were delayed. One staff member mentioned staying after their shift to complete showers, indicating a lack of sufficient staff to meet residents' needs during regular hours. The facility's staffing data showed a one-star staffing quality rating and excessively low weekend staffing, further emphasizing the staffing deficiencies.
Improper Food Storage and Labeling in Facility
Penalty
Summary
The facility failed to properly label and date food items stored in the A-Hall refrigerator, which included a container with a red-colored food item, an unknown food substance, a Subway food item, a Sysco nutritional drink, and a Premier Protein shake. These items were either not labeled or dated, contrary to the facility's policy that requires perishable foods to be stored in resealable containers with labels indicating the resident's name, the item, and the use-by date. This oversight was confirmed during an interview with a staff member who stated that perishable food items kept by residents should be labeled, dated, and stored in the nourishment refrigerator. Additionally, the facility did not maintain the walk-in freezer at the appropriate temperature to ensure food remained frozen solid. Observations revealed that the freezer's temperature gauges read between 18 and 24 degrees Fahrenheit, which is above the required 0 degrees Fahrenheit. As a result, food items such as sliced zucchini, a package of meat resembling bacon, and a breaded food item were not frozen solid. The facility's records indicated that the freezer maintenance was overdue, with a high-priority work order due earlier in the month. This failure to maintain proper storage conditions increased the risk of residents receiving contaminated food.
Inadequate Infection Control During COVID-19 Outbreak
Penalty
Summary
The facility failed to maintain proper infection control practices during a COVID-19 outbreak, affecting several residents and staff. Observations revealed that there was no signage at the facility entrance to notify visitors of the outbreak, and no screening process was in place for visitors entering the building. Staff were not adequately trained on the proper use of personal protective equipment (PPE), with some staff using procedural masks instead of N95 or KN95 masks, and others not wearing eye protection when required. Additionally, residents were not encouraged to wear masks outside their rooms, and some residents on droplet precautions were observed with open doors, contrary to recommended practices. Resident #21, who tested positive for COVID-19, was observed without a mask in common areas, interacting with others, and eating in the dining room with other residents. There was confusion among staff regarding the status of residents on precautions, with some staff unaware of the outbreak's start date or the correct PPE protocols. The facility's infection control binders were outdated, and there was a lack of clear communication to visitors about the outbreak, as evidenced by a visitor who was unaware of the COVID-19 cases in the facility. In addition to the COVID-19 related deficiencies, the facility also failed to properly dress a wound using aseptic technique for a resident. During a wound dressing change, staff did not change gloves between cleaning the wound and applying clean dressings, increasing the risk of infection. This highlights a broader issue of inadequate infection control practices and staff training within the facility.
Inaccurate Documentation of DNR Orders in EHR and Care Plans
Penalty
Summary
The facility failed to ensure that the current Do Not Resuscitate (DNR) orders were accurately reflected in the electronic health records (EHR) and care plans for two residents. For one resident, the Montana Provider Orders for Life-Sustaining Treatment (POLST) indicated a preference for resuscitation, yet the care plan and EHR dashboard incorrectly documented a DNR status. This discrepancy between the POLST and the care plan/EHR dashboard could lead to the resident's wishes not being honored. Similarly, another resident's POLST indicated a preference for resuscitation, but the EHR dashboard and physician orders documented a DNR status. Additionally, the care plan for this resident did not include any advance directive or code status. Interviews with staff revealed that the POLST is reviewed quarterly and that changes to advance directives are typically managed by social services, with the director of nursing services or designee responsible for notifying the attending physician of any changes. The facility's policy requires that the plan of care be consistent with the resident's documented treatment preferences, which was not adhered to in these cases.
Failure to Update Care Plans for Bathing and Transfer Preferences
Penalty
Summary
The facility failed to revise individualized comprehensive care plans to accurately reflect the preferences and needs of residents regarding bathing and transfer methods. For one resident, the care plan did not include her preference for bed baths, despite her expressing dissatisfaction with the regularity of her bathing routine and her preference being noted in a social services document. Staff interviews revealed inconsistencies in the inclusion of bathing preferences in care plans, with one staff member indicating that preferences are only added under extenuating circumstances. Additionally, the facility did not update the care plans for two residents to reflect their current transfer methods. One resident reported that staff no longer used the Hoyer lift for transfers, and staff confirmed using a stand pivot transfer instead, which was not documented in the care plan. Another resident expressed fear of the Hoyer lift and stated that a sit-to-stand lift was used instead, yet the care plan still indicated the use of a Hoyer lift. These discrepancies between the care plans and actual practices could potentially lead to improper transfer methods being used, posing a risk of injury to the residents.
Improper Use of Lift Leads to Resident Drop
Penalty
Summary
The facility failed to provide a safe environment during the transfer of a resident using a lift, which resulted in an accident. A resident was being transferred with a Hoyer lift when the lift malfunctioned, causing the resident to be dropped onto the bed. The incident occurred because the staff used a smaller Hoyer lift with a scale, instead of the required 700-pound capacity lift as specified in the resident's care plan. The staff member involved in the transfer was unfamiliar with the larger lift, which was reportedly stored in a different location and appeared old. This incident was documented in the resident's progress notes and care plan, highlighting the failure to anticipate and assess the resident's needs related to transfers.
Failure to Provide Sufficient Hydration to Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide sufficient hydration for a resident with severe cognitive impairment, as evidenced by multiple observations and interviews. The resident, who had a history of a small bowel obstruction and was readmitted to the facility after hospitalization, was observed with dry lips and expressed thirst on several occasions. Despite the resident's request for fluids, staff members did not address his needs promptly, and there were instances where no fluids were available at the resident's bedside. The resident's electronic health record (EHR) indicated a recommendation for a daily fluid intake of 2,632 ml, with encouragement from staff to ensure adequate hydration. However, observations showed that the resident was not consistently provided with fluids, and staff interviews revealed a lack of proactive measures to encourage fluid intake, particularly given the resident's medical history and cognitive impairment. This deficiency had the potential to affect all residents with similar cognitive impairments who required staff encouragement to maintain adequate hydration.
Failure to Complete and Document Monthly Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that medication regimen reviews were completed monthly and documented in the electronic health record for two of the three sampled residents. For one resident, the medical record showed an admission date, but only one medication review was documented, with no irregularities found, and no other reviews were located or provided. For another resident, the medical record indicated several reviews were completed, but there were missing reviews for specific months, including on admission. During an interview, a staff member stated that medication regimen reviews were done monthly by the pharmacy and sent to the facility in batches for review by QAPI and the physician. However, the staff member, who had only been at the facility since July 2024, noted that there were no staff assigned to oversee the completion of the medication reviews. The facility's document on Medication Regimen Reviews indicated that reviews should be done upon admission and at least monthly thereafter.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, with an observed error rate of 20.69% among three residents. For resident #101, staff member J did not verify the physician's admission order with the MAR when discrepancies were found. The medication cards from the hospital were incorrect, and staff member J dispensed medications based on the MAR, which led to errors. Staff member FF later confirmed the discrepancies and stated that medications would be dispensed from facility stock until verification was complete. For resident #74, staff member J also failed to verify the physician's order with the MAR when discrepancies were found. The medication card contained incorrect dosages, and staff member J was instructed to use up the card before switching to the correct dosage. Staff member FF discarded an almost empty insulin pen and replaced it with a new one, following the MAR order. For resident #73, staff member F did not usually dispense medications and failed to verify the order before dispensing. She relied on the computer order, which was considered up-to-date, and dispensed medication from the stock. Staff member B later stated that medication cards from other facilities should not be used, and any remaining medication from changed orders should be destroyed.
Infection Preventionist Lacks Required Certification
Penalty
Summary
The facility failed to ensure that the designated infection preventionist was qualified through an approved certification program before assuming the role. This deficiency was identified during an interview and record review, where it was revealed that the staff member responsible for infection prevention had only completed three out of fifteen required training modules. The staff member acknowledged being aware of existing infection control issues at the time of hiring and had not yet completed the necessary CDC training. The job description for the position required certification in Infection Control and Epidemiology, which the staff member did not possess at the time of the survey.
Inaccessible Call Lights Cause Distress for Residents
Penalty
Summary
The facility failed to ensure that the call light button was within reach for two residents, leading to distressing situations for both. Resident #46, who was on Transmission Based Precautions for COVID-19, was found with the call light across the room, draped on a pedal exercise device on the floor. She expressed feeling panicked and scared when she was unable to reach the call light after staff left her dinner tray and did not check on her for several hours. Despite being checked frequently during the day, the call light was not accessible, causing her to call her sister for comfort. Similarly, resident #18 was found calling out for help because her call light was not activated. The call light was located behind her recliner, inside a partially closed drawer, making it inaccessible. Staff member Q confirmed that call lights should be placed within reach and on the resident's strong side if they have weakness. The facility's document, "Answering the Call Light," emphasized the importance of ensuring call lights are accessible from various locations, including the bed, toilet, and bathing facilities.
Failure to Provide Quality Care and Address Severe Weight Loss
Penalty
Summary
The facility failed to provide quality care services to a skilled care resident admitted for rehabilitation and nursing care, resulting in a severe weight loss of 21.8% without implementing nutritional interventions to prevent further loss. The resident's vital signs were not obtained, documented, or assessed as ordered by the physician, and the facility did not follow physician orders. Additionally, the facility failed to assess and identify the resident's behavioral care needs, including pain management, and ensure documentation was included in the electronic health record (EHR). Prior to the resident's transfer to the emergency room, nursing staff did not sufficiently assess and address a significant change in condition, including a decline in respiratory status, which contributed to the resident's death on the same day of transfer. The resident was admitted to the facility weighing 110 pounds and was found to weigh 88 pounds at the hospital after a change in condition. The resident experienced a fall, lost consciousness, and was sent to the hospital where he was diagnosed with sepsis. The facility's staff noted signs of pain, such as teeth clattering and moaning, but failed to adequately address these symptoms. The resident's meal intake records showed significant decreased intake, and there were multiple instances of missed documentation for meal consumption. Despite the resident's severe weight loss, no nutritional assessment or interventions were implemented during his stay at the facility. The resident's physician orders included oxygen therapy, which was not consistently applied, and the resident was not seen by a physician during his stay. The facility's nursing notes and assessments did not adequately document the resident's condition, including his pain levels and cognitive status. The resident's fall assessment indicated issues with mobility, pain, and respiratory status, but these were not effectively managed. The resident's emergency room records showed he was in significant respiratory distress and pain upon arrival, leading to end-of-life care being provided. The facility's failure to address these deficiencies resulted in an Immediate Jeopardy situation, which was later downgraded upon removal of immediacy.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 51 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Helena
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mount Ascension Transitional Care Of Cascadia | 0.5 mi | ★★★★★ | 28 | 0 |
| Elkhorn Healthcare And Rehabilitation | 9.1 mi | ★★★★★ | 23 | 0 |
| Ivy At Deer Lodge | 37.2 mi | ★★★★★ | 10 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.