Cooney Healthcare And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Helena, Montana.
- Location
- 2555 E Broadway, Helena, Montana 59601
- CMS Provider Number
- 275080
- Inspections on file
- 29
- Latest survey
- December 31, 2025
- Citations (last 12 mo.)
- 66
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.
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.
A resident with a recent femur fracture repair and under comfort measures only experienced a decline in status after an unwitnessed fall. Despite standing orders to apply oxygen for saturations below 89%, the facility staff failed to provide supplemental oxygen when the resident's saturation dropped to 75%. The resident was later transferred to the ER in significant respiratory distress and required end-of-life care.
A resident experienced negative outcomes due to the facility's failure to adhere to professional standards of care. The staff did not apply supplemental oxygen when the resident's saturation levels dropped, nor did they adequately assess and address non-verbal indicators of pain following a hip fracture. Additionally, there was insufficient monitoring of the resident's nutritional intake and bowel movements, leading to significant weight loss and undetected black tarry stools.
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.
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.
Failure to Provide Supplemental Oxygen to Resident
Penalty
Summary
Facility nursing staff failed to provide supplemental oxygen to a resident whose oxygen saturation level dropped to 75%, despite standing orders to apply oxygen at two liters via nasal cannula for saturations less than 89%. The resident, who had a history of a recent femur fracture repair and was under comfort measures only, experienced a decline in status following an unwitnessed fall. The fall documentation noted the resident was drowsy, had a decreased level of consciousness, and sustained skin tears but did not show that oxygen was applied when his saturation was critically low. The resident was later transferred to the emergency room with a chief complaint of shortness of breath and was found to be in significant respiratory distress with a pulse oximetry of 70% on room air. The emergency room records indicated the resident was confused, disoriented, and in pain, requiring end-of-life care. Interviews with facility staff revealed that the resident had been on oxygen at the facility but had a tendency to remove it. Despite this, the necessary intervention of applying oxygen was not documented or performed at the time of the fall, contributing to the resident's decline and subsequent transfer to the hospital.
Deficiencies in Resident Care and Documentation
Penalty
Summary
The facility failed to ensure that nursing staff adhered to professional standards of practice in several critical areas, leading to negative outcomes for a resident. The deficiencies included inadequate assessment and intervention for a resident's change in condition, particularly concerning the use of supplemental oxygen when the resident's oxygen saturation levels dropped to 75%. Despite the resident's low oxygen levels, staff did not apply oxygen as required, and there was a lack of ongoing assessment and documentation of the resident's condition, including vital signs and oxygen needs. Additionally, the facility did not adequately assess and address non-verbal indicators of pain for the resident, who had a history of a fractured hip. The resident exhibited signs of pain such as anger, agitation, and confusion, yet there was no evidence of ongoing monitoring or administration of pain medication during the period in question. The resident's care plan included interventions for pain management, but these were not effectively implemented, as evidenced by the lack of documentation and response to the resident's behaviors and condition. The facility also failed to monitor and document the resident's nutritional intake and bowel movements accurately. The resident experienced a significant decrease in meal intake, and there was no timely assessment of weight loss. Furthermore, the documentation of bowel movements lacked descriptive details, such as color, which was crucial as the resident was later found to have black tarry stools upon hospital admission. These cumulative failures in care and documentation contributed to the immediate jeopardy situation identified by surveyors.
Latest citations in Montana
A resident with a history of hematuria, renal failure, anemia, and recent blood transfusions was readmitted from the hospital with discharge instructions to pause apixaban, but the facility failed to obtain admission orders and did not clarify the incomplete anticoagulant order. The resident’s care plan did not address anticoagulant use or monitoring, and staff administered multiple doses of apixaban after readmission. Nursing notes documented blood in the nephrostomy drainage bag on two days without provider notification or intervention, followed by worsening weakness, poor intake, and hypoxia that led to hospital transfer. Hospital records showed the resident had gross hematuria, hypotension, respiratory distress, acute kidney injury, and a critically low Hgb requiring transfusion, and a late entry note acknowledged that the discharge order to hold apixaban had been overlooked.
A resident who was cognitively intact but dependent for bowel and bladder care and limited in ROM reported that a specific staff member repeatedly left call lights unanswered for extended periods, causing the resident to soil briefs and then be pressured to ambulate to the bathroom and sign refusal-of-care forms. A family member corroborated long call-light waits and rude interactions, and staff noted the resident became anxious and displayed behaviors when care was forgotten or incomplete. Despite verbal reports, emails, and documentation at a care conference describing long call-light waits, incontinence episodes, and refusal forms used at night, no grievance was filed and the alleged neglect was not reported or investigated. The resident also developed unaddressed skin issues on the heels, coccyx, and ears, and +2 pitting edema in both feet and ankles, with offloading devices found unused in the room and no related wound orders or documented weekly skin assessments.
Multiple residents experienced inadequate pressure ulcer and skin care when staff failed to perform timely and accurate skin assessments, obtain and follow wound care orders, and implement appropriate care plan and nutritional interventions. One resident admitted with multiple skin issues developed a large, foul-smelling coccyx ulcer that was not promptly evaluated, lacked early wound orders, and was not reflected in the care plan or consistently documented on the TAR. Another resident with a coccyx pressure injury and a spinal incision had delayed wound measurements, late dietitian notification, missed daily wound treatments, and late addition of protein supplementation to the care plan. A resident using oxygen had painful, reddened ears and heel/eschar issues that were not captured in admission documentation, lacked wound orders, and had no subsequent skin assessments recorded. A further resident with a coccyx pressure ulcer had conflicting MDS staging and "present on admission" coding, along with numerous days where ordered daily wound care was undocumented or absent. Staff interviews revealed inconsistent weekly skin checks, missed admission skin evaluations due to EHR changes, limited dietitian availability, and wound care being performed by staff without formal wound training, all contrary to the facility’s own skin integrity policy.
The facility failed to thoroughly investigate, monitor, and document multiple abuse allegations involving staff-to-resident and resident-to-resident incidents. In one case, a resident reported that a staff member blew marijuana vape smoke in his face, but there was no related nursing documentation or post-incident monitoring. In another case, a resident reported being hit by another resident, was found with a red mark on the head, and was sent to the ER, yet nursing notes for both residents lacked documentation of the incident and follow-up monitoring. In a third case, a cognitively impaired resident with developmental delay was found in another resident’s room while that resident’s hands were being removed from inside the resident’s pants and shirt, after which the resident complained of pain and was sent to the ER; again, nursing notes for both residents contained no documentation of the event or post-incident monitoring, and the investigator did not fully interview or obtain written statements from all involved as required by facility policy.
The facility failed to thoroughly investigate multiple allegations of abuse and neglect, including one resident’s report that a staff member was verbally demeaning and rushed her during oral care, and another resident’s report of inadequate ADL care with prolonged call light response times and being left in a soiled brief. A staff member admitted not reporting or investigating the latter allegation, and no related documentation was produced. In a separate incident, a resident alleged a CNA turned off the call light and refused requested personal care; the facility interviewed only the involved staff and did not interview other residents who might also have experienced call lights being turned off without care being provided, despite a witness stating this was a common practice by multiple staff. Additional requested interviews and information were not provided to surveyors.
Surveyors found that the facility failed to complete timely and comprehensive baseline care plans for three newly admitted residents. One resident with multiple serious conditions and a coccyx wound had no baseline care plan addressing wound care, pain, or chronic conditions for several days after admission. Another resident with dysphagia, dementia, and documented skin issues on the buttocks, heels, and knee had a baseline care plan that did not identify pressure wounds or related treatments. A third post‑surgical resident with a Stage 3 pressure ulcer and a lumbar incision had a baseline care plan that omitted wound management and post‑operative pain control. A staff member reported that baseline care plans are only generated after the admission nursing assessment is completed and locked, and acknowledged they are not always completed on time.
A resident’s long-time friend, a former employee previously terminated over an abuse allegation, was barred from entering the facility when she attempted to visit, and was told law enforcement would be called if she returned. Another individual confirmed awareness of the restriction, expressed no concern about the friend abusing the resident, and stated that the facility did not offer supervised or common-area visits. A staff member reported that any former employee terminated for an abuse allegation was categorically prohibited from returning to the building, without considering the resident’s relationship with the visitor, despite a visitation policy stating residents have the right to receive visitors of their choice and allowing only limited or supervised access when abuse is suspected or found.
The facility failed to follow its grievance policy by not documenting or investigating a grievance request from a resident and family member alleging that a CNA ignored call lights for extended periods, failed to provide timely ADL care, forced ambulation to the bathroom at night, and pressured the resident to sign refusal-of-care forms, causing the resident to feel afraid and neglected. In a separate case, the facility did not adequately investigate or document a grievance from a dependent, mobility-impaired resident who reported that a male CNA was rough and refused to reposition his contracted legs for comfort, and the staff member assigned to the investigation did not identify the CNA involved or record her explanation of the situation on the grievance form.
A resident reported that a former staff member repeatedly left the call light unanswered for extended periods, did not provide needed ADL assistance, and encouraged the resident to sign refusal-of-care forms, resulting in the resident soiling briefs before being asked to ambulate to the restroom. Another staff member stated that no care concerns had been brought to their attention and acknowledged that the alleged abuse and neglect were not reported. When surveyors requested IDT notes, root cause analysis, reporting, and investigation documents related to the staff member and this resident, the facility was unable to provide any documentation, indicating the allegation was not timely reported to the State Survey Agency or investigated.
Surveyors found that several residents did not receive appropriate ADL and hygiene assistance or accurate documentation of those services. A dependent resident reported inconsistent help with meals, only sponge baths instead of showers for several weeks, lack of shaving, and prior grievances about staff not assisting with a urinal or repositioning his legs. Another cognitively intact resident, dependent for oral care and dressing, stated he was not offered mouthwash or a warm washcloth, and staff confirmed they had never offered mouthwash despite charting that personal hygiene was provided. A third resident, largely independent with self-care, reported that washcloths were not available unless requested, and no washcloths were seen in the room, while documentation showed staff performing most of her personal hygiene. These findings showed failures to offer basic hygiene items and to accurately document ADL care provided.
Failure to Clarify Anticoagulant Orders Leads to Unnecessary Drug Administration and Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s drug regimen was free from unnecessary drugs when nursing staff did not clarify and correctly implement anticoagulant orders upon the resident’s readmission. The resident had been hospitalized for hematuria, renal failure, and anemia, received multiple blood transfusions, and was discharged back to the facility with an After Visit Summary instructing that apixaban (an anticoagulant) be paused, with no restart date specified. Despite this, the facility’s admission documentation for the readmission date showed no admission orders, and the apixaban order was not clarified with the physician. The medication was restarted and administered after readmission, even though the hospital documentation indicated it was to be paused and later discontinued. Following readmission, the resident’s Medication Administration Record showed that seven doses of apixaban were given. The resident’s care plan, initiated on the readmission date, did not identify any problems, goals, or interventions related to anticoagulant use, safety, or monitoring for side effects. Nursing progress notes documented that the resident had a right-sided nephrostomy with yellow urine drainage on the day of readmission, and then documented blood in the nephrostomy drainage bag on two consecutive days. However, there was no documentation that the provider was notified about the hematuria or that any action was taken in response to this change. Subsequently, nursing notes described the resident as weak, not eating, unable to maintain a sitting position, and having low oxygen saturation that did not adequately improve with increased supplemental oxygen, leading to transfer to the emergency department. Hospital records from that visit showed the resident presented with hypoxia, hypotension, profound weakness, respiratory distress, gross hematuria, acute kidney injury, and a critically low hemoglobin of 6.9 g/dL, and that the resident had received an anticoagulant and required blood transfusions. A late entry nursing note at the facility later documented that the hospital discharge summary had been overlooked, the order to hold apixaban was not implemented, and the resident continued to receive apixaban until readmission to the hospital. The facility’s root cause analysis attributed the event to ambiguity in discharge communication and medication reconciliation workflow and noted that the apixaban order was incomplete and not clarified before administration.
Failure to Identify and Address Neglect, Call-Light Delays, and Skin Concerns
Penalty
Summary
The deficiency involves the facility’s failure to identify, report, and address neglect of care concerns for a cognitively intact resident who was dependent on staff for bowel and bladder care and had range of motion limitations in both upper and lower extremities. The resident reported that a specific staff member (NF7) repeatedly left his call light on for extended periods, often over 45 minutes and up to hours at night, resulting in him soiling his brief with bowel and bladder incontinence while waiting for assistance. When staff eventually responded, NF7 would attempt to have the resident ambulate to the restroom despite the resident already being incontinent, and would then encourage him to sign refusal of care forms when he declined. The resident described being upset, anxious, and irritable, and stated he usually “peed” and “soiled” his pants and developed skin issues from sitting so long without being cleaned. A family member (NF6) corroborated concerns about long call light response times, stating the resident’s call light was left on for over an hour, leading to incontinence episodes, and that NF7 spoke to the resident in a rude and angry manner. NF6 reported these concerns in person, by phone, and by email to facility staff, including staff members A and C. Staff member O reported that the resident had anxiety and behaviors that were exacerbated when staff forgot about him or failed to perform all required care. Despite these reports and the resident’s expressed fear and anxiety when NF7 was working, no staff member asked the resident if he felt safe or explored what had occurred on nights with or without NF7, and the alleged neglect was not reported or investigated by facility leadership. The resident also had unaddressed skin concerns and edema that were not properly identified or managed. Staff member B stated weekly skin assessments should have been done but that wound care staff were unaware of any ear or coccyx issues, and the physician orders lacked wound orders for the resident’s left heel. On assessment, staff member P observed eschar on the left heel that appeared to need debridement, redness and cracking on the right heel, pink coccyx, and reddened ears, with delayed capillary refill on one ear, as well as +2 pitting edema in both feet and ankles that had developed during the resident’s stay. Posey boots intended to offload the heels were found in the resident’s cabinet, and staff member P stated she had never seen them used on the resident. Additionally, at a care conference documented and signed by staff member C, the resident reported waiting 20–40 minutes for call lights at night, having accidents while waiting, and being made to sign refusal papers when he declined to go to the bathroom after already being wet. Despite this documentation of neglect-related concerns, no grievance was filed, and staff members B and C stated they were unaware of or did not report or investigate any alleged abuse or neglect for this resident.
Failure to Assess, Document, and Treat Pressure Ulcers and Related Skin Conditions
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain an effective system for pressure ulcer prevention, identification, assessment, and treatment for multiple residents. For one resident admitted with existing skin issues on the buttocks, both heels, and a right knee wound, nursing notes documented a silicone foam dressing on the coccyx that was saturated with foul-smelling brown-yellow drainage, and a non-stageable pressure ulcer with slough, black eschar, and a large reddened border. This was the first detailed description of the coccyx pressure ulcer, and there were no wound care orders in the chart at that time. A subsequent weekly skin evaluation described a large, deep coccyx wound with copious foul-smelling drainage and extensive slough and granulation tissue, but incorrectly listed that date as the first observation despite the wound being identified nine days earlier. Wounds on the left heel, right outer ankle, and right knee were not evaluated until several days after admission, and the right heel was never evaluated during the stay. The resident’s care plan did not identify pressure ulcers as a problem and contained no interventions for pressure ulcer care or nutrition to support wound healing, and the treatment administration record showed wound treatments were not ordered until several days after admission and were then not consistently documented as completed. Another resident was admitted with a coccyx area that was open and possibly caused by pressure, and a late entry note identified a Stage 3 pressure ulcer to the coccyx from admission. However, the nutrition evaluation form later indicated “no” to the presence of a pressure injury and instead listed “other skin condition,” even though coccyx wound care was ordered. The weekly skin evaluation documented the first observation and measurements of the coccyx wound two weeks after admission, and the dietitian was not notified until several days after that. The treatment record showed that daily wound care orders for both the coccyx pressure ulcer and a surgical spine incision were not carried out on at least two days. Nutritional interventions to support wound healing, including a protein supplement, were not added to the care plan until more than two weeks after the wound was identified. Staff interviews revealed that the dietitian was only present in the facility limited hours on two days per week, that residents admitted later in the week might not be assessed nutritionally until the following week, and that a fourteen-day delay in nutritional assessment, while allowed, was acknowledged as not best practice for residents with wounds. A third resident using oxygen reported pain behind both ears, and observation showed that oxygen tubing protectors had slid out of place, leaving the ears unprotected. The right ear was red where the tubing rested, and the left ear was very red with a whitish substance in the crease. Staff later described this resident’s skin as having eschar on the left heel that appeared to need debridement, a red and cracked right heel, a pink coccyx, and reddened ears, with the left ear showing slower capillary refill. The facility’s records contained no wound orders for the left heel, no skin assessments since the most recent readmission, and an admission nursing evaluation that documented the skin as warm, dry, intact, and without wounds. A fourth resident had a coccyx pressure ulcer that was present on admission and gradually decreasing in size according to wound assessments. However, MDS assessments contained inconsistent documentation: one assessment showed no unhealed pressure ulcers on admission, a later discharge assessment documented a Stage IV pressure ulcer present on admission, and a subsequent quarterly assessment documented a Stage III pressure ulcer not present on admission. Treatment administration records showed no coccyx wound treatment in one month, initiation of daily wound care late in the following month with at least one missed documented treatment, and in the next month, daily wound care orders with more than half of the scheduled treatments lacking documentation of completion. In the subsequent month, the TAR failed to show any wound care performed for the coccyx pressure ulcer. Staff interviews indicated that weekly skin checks were the facility practice but were not consistently completed, that nurses were not always coding or documenting wounds correctly, and that admission skin evaluations were sometimes not done due to issues with a new computer system. A staff member performing wound care on one resident’s coccyx reported having no formal wound training and described a wound bed fully covered with thick yellow-tan slough, which, according to the cited National Pressure Ulcer Advisory Panel guideline, could not be accurately staged, despite the facility’s practice of staging it as a Stage III pressure ulcer. The facility’s own Skin Integrity policy required that upon admission, the licensed nurse establish a plan of care based on risk factors or presence of wounds, conduct ongoing weekly full-body skin audits, document new skin impairments with detailed characteristics and measurements, record qualifying wounds on the weekly skin evaluation form, notify the medical provider and obtain treatment orders, notify the resident or representative, notify the registered dietitian, and implement and document appropriate care plan interventions. The findings across these residents showed that these policy steps were not consistently followed: admission and weekly skin evaluations were missed or delayed, wounds were not accurately or timely documented or staged, treatment orders were delayed or not consistently carried out, nutrition and care plan interventions for wound healing and prevention were not promptly implemented, and staff responsible for wound care sometimes lacked formal wound training.
Failure to Thoroughly Investigate and Document Multiple Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to complete thorough investigations, monitoring, and documentation for multiple abuse allegations. In one incident, a resident reported that a staff member blew marijuana vape smoke in his face. The staff member later admitted to vaping marijuana in the resident’s room. Despite this, the resident’s nursing progress notes for the period following the incident contained no documentation of the event or any post-incident monitoring, and the psychosocial impact assessment tool indicated that no ALERT charting had been done by nursing or social services. In a second incident, a resident sitting in a wheelchair by the nurse’s station told a staff member that another resident had hit him; assessment revealed a red mark on the resident’s head, and the resident was sent to the emergency room at the family’s request. However, nursing progress notes for both the alleged victim and the alleged aggressor for the days following the incident contained no documentation of the incident or any post-incident monitoring. The staff member responsible for the investigation stated that he relied on video footage and interviews with the two residents, but these interviews were only documented in the incident report, and no other staff or residents on shift were interviewed. In a third incident, staff found one resident in another resident’s room and observed the second resident removing his hands from inside the first resident’s pants and shirt; the first resident later stated, “It hurts down there,” and was sent to the emergency room. The first resident had diagnoses including unspecified symptoms involving cognitive functions and awareness, anxiety, depression, cerebral infarct, and was described as having a developmental delay with the mentality of an 8-year-old, while the second resident was cognitively intact based on a BIMS score of 14. Nursing progress notes for both residents for the days following the incident contained no documentation of the event or any post-incident monitoring. The staff member overseeing the investigation acknowledged that he did not document his post-incident checks, did not interview staff on shift or other residents, and no abuse education or protective measures for staff were documented, contrary to the facility’s abuse prevention policy that requires interviews with all involved, retrieval of written statements, and documentation of assessments and monitoring.
Failure to Thoroughly Investigate Allegations of Abuse and Neglect
Penalty
Summary
The deficiency involves the facility’s failure to fully investigate multiple allegations of abuse and neglect, including not identifying all potentially affected residents. One resident reported that a staff member (NF8) was “nasty and pushy” while assisting with oral care, telling her she should not take so long brushing her teeth because she only had eight teeth and making her hurry without giving her the time she needed. When the facility questioned NF8 about this incident, he resigned from his position. Review of the facility-reported incident showed no staff interviews were completed as part of the investigation, despite the importance of such interviews in understanding the incident and identifying root causes. Another resident reported inadequate ADL care by staff member NF7, including long call light response times and being left in a soiled brief for hours, and stated he had reported these concerns to facility staff. A staff member later stated they were unaware of any concerns from the resident or his family regarding NF7 and acknowledged they did not report or investigate the alleged abuse or neglect. When surveyors requested documentation such as interdisciplinary team notes, root cause analysis, reporting, and investigation related to concerns with NF7, none was provided. In a separate facility-reported incident, a resident alleged a CNA turned off the call light and refused to provide requested personal care. The facility interviewed only the staff involved that night and did not interview other residents who might have been affected by staff turning off call lights without providing care. A witness (NF5) reported that it was the facility’s usual practice to turn off call lights without providing help, that staff often told the resident they would return but did not always do so, and that multiple staff engaged in this behavior. Despite a request from surveyors, the facility did not provide additional resident interviews or information regarding this allegation by the end of the survey.
Failure to Complete Timely Baseline Care Plans for Wounds and Pain Management
Penalty
Summary
The deficiency involves the facility’s failure to complete timely and comprehensive baseline care plans that provided instructions for resident-centered care for three residents. One resident was admitted with multiple serious diagnoses, including acute kidney failure, anemia, atrial fibrillation, chronic respiratory failure, hypertension, a right femur fracture, morbid obesity, and muscle weakness. A nurse progress note documented a coccyx wound described as stage I open on the day of admission, yet no baseline care plan was initiated to direct staff in caring for the wound, managing pain, or addressing the resident’s chronic medical conditions. A care plan was not started until several days later, and when it was initiated, it only addressed advanced directives, oral/dental health problems, loneliness, and discharge planning, without including wound or pain management. Another resident was admitted with dysphagia, dementia, behaviors, a history of falls, and a urinary tract infection. Nursing progress notes documented skin issues on the buttocks, both heels, and the right knee, but the baseline care plan initiated the same day did not identify pressure wounds or any treatment for those wounds. A third resident, admitted after surgical repair of a lumbar 4 compression fracture, had a documented Stage 3 pressure ulcer and a lower back incision with intact staples on the admission nursing evaluation. However, the baseline care plan for this resident did not include wound management interventions or pain management for post-operative pain. During an interview, a staff member explained that the baseline care plan is triggered when the admitting nurse completes and locks the admission nursing assessment, and acknowledged that when assessments are not locked, baseline care plans are not completed and are not always done on time.
Failure to Honor Resident’s Right to Chosen Visitor
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to receive visitors of her choosing. A long-time friend of the resident, identified as NF1, reported that when she first attempted to visit the resident after the resident’s admission, staff member B escorted her out of the building and told her that law enforcement would be called if she returned. NF1 had previously been employed by the facility approximately four years earlier and had been terminated due to an allegation of abuse toward a resident. The facility did not allow her to visit the resident in any capacity. Another individual, NF2, stated he was aware that the facility was not allowing NF1 to visit the resident and that he knew about the prior abuse allegation but was not concerned about NF1 abusing the resident. NF2 stated he wanted NF1 to be allowed to visit and that the facility did not offer supervised visits or visits in a common area. He was hesitant to raise the visitation issue with the facility because he was concerned it might change how the resident was treated. Staff member B confirmed that any employee terminated due to an abuse allegation was not allowed to return to the building for any reason, and that this restriction was applied without considering the resident’s history with the visitor. The facility’s visitation policy stated residents have the right to receive visitors of their choice and that limitations may include denying or limiting access to individuals suspected of abuse until an investigation is completed or abuse is found, but the facility applied a blanket prohibition in this case.
Failure to Document and Investigate Resident Grievances Alleging Neglect and Inadequate Repositioning
Penalty
Summary
The deficiency involves the facility’s failure to follow its grievance policy and to ensure residents could voice grievances related to alleged abuse and neglect without discrimination or reprisal. One resident reported that a specific CNA (NF7) left his call light on for hours, did not assist with ADLs, and that this led to bowel and bladder incontinence while he waited for help at night. The resident stated that when the CNA finally responded, the CNA would force him to ambulate to the restroom instead of cleaning him in bed, and when the resident refused to ambulate, the CNA told him to sign a refusal of care form. The resident reported being afraid of this CNA and feeling neglected in his care, and he stated he reported these concerns to staff member C. An external email from NF6 to staff member C documented that the resident was afraid of NF7, described NF7’s statements about his job duties, and explicitly requested to file a grievance and have NF7 kept away from the resident. Additionally, a care conference note signed by staff member C documented the resident’s report of being made to sign refusal sheets at night and waiting 20–40 minutes for call lights to be answered. Despite this, staff member C, identified as the grievance official, stated there were no concerns brought forth from the resident or family regarding NF7, and no grievance was completed for this abuse/neglect allegation as required by the facility’s grievance policy. The deficiency also includes the facility’s failure to thoroughly investigate and document findings for another resident’s grievance regarding care. This resident, who had impaired mobility in both upper and lower extremities and was dependent for all ADLs except eating, reported that a night CNA was rough and refused to reposition his legs, and he stated he had complained to the facility but the issue continued. A written grievance from this resident documented that a male CNA would not readjust his legs for comfort. The grievance form’s investigative findings did not show any attempt to identify the specific night CNA involved or to clarify what care was being refused. Staff member E, who was responsible for investigating this grievance, could not recall details of the investigation and acknowledged she did not attempt to identify the accused CNA, characterizing the issue as a recurrent complaint and a miscommunication about repositioning due to the resident’s leg contractures. She stated she had encouraged the resident to be more specific about the repositioning requested but could not explain why this was not documented on the grievance form. The facility’s grievance policy required that grievances, including those involving abuse or neglect, be documented on a grievance form and investigated, but this was not done in accordance with policy for these residents’ complaints.
Failure to Timely Report Alleged Abuse and Neglect to State Agency
Penalty
Summary
The facility failed to timely report an allegation of abuse and neglect to the State Survey Agency involving one sampled resident, identified as resident #47. During an interview, resident #47 reported that a specific former staff member, NF7, would leave his call light on for hours, fail to assist with ADL care, and this lack of response resulted in the resident soiling his brief with bowel and bladder because he waited so long for help. The resident further stated that NF7 would encourage him to sign a refusal of care form and then expect him to ambulate to the restroom after he had already gone in his brief. In a separate interview, staff member B stated that no care concerns from the resident or family had been brought to their attention and acknowledged that they did not report the alleged abuse or neglect of care. A request by surveyors for documentation related to resident #47’s interdisciplinary team notes, any identified root causes, reporting, and investigation of concerns involving NF7 and resident #47 yielded no documentation by the end of the survey, demonstrating a lack of evidence that the allegation was reported or investigated as required.
Failure to Provide and Accurately Document ADL and Hygiene Assistance
Penalty
Summary
Surveyors identified that the facility failed to provide and accurately document assistance with activities of daily living (ADLs) for multiple residents. One resident, who was assessed on the MDS as dependent for all ADLs except eating (requiring only partial to moderate assistance with eating), reported not always receiving help with meals, having only sponge baths for several weeks instead of showers, and needing a shave while observed lying in bed in a hospital gown with several days of facial hair growth. This same resident had previously filed a grievance stating that a night nurse would not assist with use of a urinal despite his inability to do this himself, and that a male CNA would not readjust his legs for comfort. These findings showed a lack of consistent ADL assistance for a resident documented as dependent. Surveyors also found failures related to personal hygiene supplies and documentation for two other residents. One cognitively intact resident, dependent for oral hygiene and dressing, stated he had not been offered mouthwash or a warm washcloth to wash his face that day, and no mouthwash was present in his room; staff later confirmed they had never offered him mouthwash, despite documentation that personal hygiene was offered and that staff did most of the activity. Another resident, who stated she could wash her face, brush her teeth, and comb her hair mostly independently, reported that washcloths were never available unless she specifically asked staff, and on observation there were no washcloths in her room. Her EHR documentation showed staff did most of her personal hygiene activity, while staff later stated she was generally independent and that they had not been giving her a daily washcloth. These discrepancies demonstrated inaccurate ADL documentation and failure to routinely offer basic hygiene items such as washcloths and mouthwash.
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