Copper Ridge Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Butte, Montana.
- Location
- 3251 Nettie St, Butte, Montana 59701
- CMS Provider Number
- 275060
- Inspections on file
- 21
- Latest survey
- April 14, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Copper Ridge Health And Rehabilitation Center during CMS and state inspections, most recent first.
Staff failed to ensure call lights were accessible for four residents, resulting in situations where individuals could not call for help when needed, including after a fall and during a respiratory complaint. Additionally, a resident with dementia and a history of wandering was not adequately supervised, leading to multiple incidents of elopement, including exiting through a window. Documentation of required safety checks was incomplete, and staff were unaware of who restricted access to call lights or why supervision protocols were not followed.
Staff did not consistently follow or understand Enhanced Barrier Precautions (EBP) for a resident with an indwelling medical device, as evidenced by staff entering and assisting the resident without required PPE and expressing confusion about EBP protocols, despite facility policies and signage indicating the need for gowns and gloves during high-contact care activities.
Multiple residents experienced unaddressed wall and baseboard damage in their rooms, with concerns about delayed repairs due to inconsistent maintenance request procedures. Additionally, a resident's room remained unclean for several days, with visible soiling on bathroom fixtures and surfaces, despite facility policies requiring daily cleaning and disinfection. Staff interviews revealed lapses in both maintenance and housekeeping routines.
A resident with a height of 6 feet 8 inches and weighing 337 pounds was admitted without the facility having the proper bed or equipment to accommodate his size. Staff improvised by attaching a piano bench to the end of a standard bed and using pillows to fill gaps, as the correct extension piece was not available until the next day. Staff later acknowledged that the admission process would have differed if they had known about the resident's height.
A staff member removed a resident's oxygen during the admission process to obtain a weight, leading to signs of hypoxia. The resident required seven liters of oxygen, which was not available in a portable form. Staff interviews indicated the removal was not willful abuse but due to inadequate preparation and resources, highlighting a lapse in protocol adherence.
A resident experienced symptoms of hypoxia after their oxygen was removed during the admission process, leading to nausea and vomiting. The incident was not reported to the State Survey Agency within the required timeframe, and staff interviews revealed confusion about reporting procedures. The facility's policy on neglect was not followed.
A resident with COPD was admitted to a facility without necessary physician orders and equipment for respiratory care. During the admission process, staff removed the resident's oxygen, leading to signs of hypoxia. The staff was unprepared and unfamiliar with the resident's needs, and the facility was not equipped with the necessary supplies, contributing to the resident's distress.
A facility failed to provide appropriate respiratory care for a newly admitted resident on high oxygen, leading to hypoxia signs after oxygen removal. Staff interviews revealed procedural misunderstandings and equipment shortages. Additionally, the facility did not follow physician orders for other residents' oxygen levels, indicating systemic issues in respiratory care and documentation.
A resident with cognitive impairments was unable to consent to sexual contact and was inappropriately touched by another resident with a history of hypersexual behavior. Despite previous incidents and measures such as medication and increased supervision, the resident was able to enter the other's room and engage in inappropriate contact. The facility's policies define such actions as sexual abuse, highlighting a deficiency in protecting vulnerable residents.
A facility failed to update a resident's care plan to protect her from unwanted sexual advances by another resident. Despite two incidents of inappropriate behavior, no interventions were added to her care plan to ensure her safety, although changes were made to the male resident's care plan. The revised care plan lacked instructions for staff on monitoring or removing her from the male resident's vicinity.
The facility failed to remove and dispose of expired medications and medical supplies in three medication rooms, three medication carts, and one wound supply cart. Additionally, wound vac supplies were improperly stored on the floor in one medication room. Staff interviews revealed that required night shift medication room and cart checks were not conducted due to a changeover in management.
The facility failed to administer respiratory treatments according to professional standards for four residents. Staff used soiled equipment, allowed residents to self-administer without orders, and did not document vital signs as required.
The facility failed to assess and document residents' ability to self-administer medications, allowing a resident to self-administer a nebulizer treatment without proper orders or assessments. Record reviews and staff interviews confirmed the lack of necessary evaluations and adherence to facility policies.
The facility failed to update the catheter care plan for a resident at risk of infection. The resident's room had a strong urine smell, and the catheter tubing was cloudy with white debris. Staff indicated that catheters are changed based on the physician's order, which was not reflected in the outdated care plan.
The facility failed to provide adequate incontinence care and repositioning for two dependent residents, leading to potential skin breakdown and discomfort. One resident was observed lying flat on her back multiple times without assistance in changing positions, while another resident was left in a wheelchair for extended periods with soaked pants and matted eyes, indicating a lack of incontinence care.
The facility failed to change a resident's catheter as ordered, leading to potential infection risk. The resident's room smelled strongly of urine, and the catheter tubing was cloudy with white debris. Staff indicated that catheters are changed based on physician orders, but records showed the catheter had not been changed in the past three months.
The facility failed to ensure staff used appropriate hand hygiene during catheter and wound care for two residents. Staff did not wash hands between glove changes and handled medical supplies with bare hands, contrary to facility policy.
Failure to Ensure Call Light Accessibility and Prevent Elopement
Penalty
Summary
Facility staff failed to ensure that call lights were accessible to four residents, resulting in situations where residents could not summon assistance when needed. One resident with left-sided weakness from a stroke was unable to reach his call light, which was tied to the bed and out of reach, leading him to call for help by yelling. Another resident, who reported difficulty breathing, did not have a call light within reach and required the surveyor to activate the call button for staff assistance. A third resident reported falling because she could not call for help before getting up, despite signage reminding her to do so, as her call light was not accessible. A fourth resident, who was unable to verbalize his needs, had his call light taped to the wall and was not able to use it, with staff unaware of who had done this. Staff interviews revealed there was no facility policy related to call lights. The facility also failed to prevent elopement for one resident with a diagnosis of unspecified mild dementia with agitation, who was known to wander and had impaired safety awareness and judgment. This resident was observed wandering the hallways, attempting to exit the building, and entering other residents' rooms without supervision. The resident had previously eloped by removing a window and screen from his room and exiting the facility, and on another occasion was found outside near the parking area. Staff interviews confirmed that the resident was on 15-minute checks, but there were missing visual check records for several days and incomplete documentation on other days. Staff also stated that the resident's door should have been open for supervision, but it was found closed multiple times without explanation. Review of the resident's care plan indicated interventions such as frequent checks and 1:1 supervision for safety and elopement risk, but these were not consistently implemented or documented. The facility's elopement policy did not specify procedures to follow after an incident report was filed. These deficiencies in supervision and environmental safety placed residents at risk of falls, injuries, elopement, or negative outcomes if a medical crisis occurred and assistance could not be summoned.
Failure to Ensure Staff Knowledge and Adherence to Enhanced Barrier Precautions
Penalty
Summary
Staff failed to adhere to and demonstrate knowledge of Enhanced Barrier Precautions (EBP) for a resident with an indwelling medical device. Multiple staff members, including one in orientation and others working independently, were observed either not knowing what EBP stood for or not following the required use of personal protective equipment (PPE) such as gowns and gloves during high-contact care activities. Staff interviews revealed confusion about when and how to use PPE, with some staff incorrectly associating EBP only with certain infections and expressing uncertainty about the full scope of required precautions. Observations included staff exiting a resident's room on EBP without PPE, and two staff assisting a resident under EBP without wearing gowns or gloves, despite signage and PPE being available. The resident's care plan specified the need for gown and glove use during high-contact activities, and facility policy outlined specific situations requiring PPE. However, staff training and understanding of these requirements were inconsistent, leading to non-compliance with established infection prevention protocols.
Failure to Maintain Safe, Clean, and Repaired Resident Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for several residents, as evidenced by multiple areas of the building in need of repair and unaddressed housekeeping issues. Observations revealed that one resident's room had numerous holes in the wall near a grab bar, another had long vertical gouges above the bed, and a third had significant wall and baseboard damage. Residents expressed concern about the lack of timely repairs, and interviews with staff indicated that maintenance requests were not consistently entered into the facility's electronic system, resulting in delays. Staff members admitted to either forgetting to log repairs or preferring to verbally request them, leading to a lack of documentation and follow-through. Additionally, the facility failed to maintain cleanliness in at least one resident's room, where a thick brown substance was observed smeared on the commode seat, handrail, and toilet paper, along with a sticky substance on the floor and a full urinal left on the bedside table. Despite daily cleaning routines outlined in facility policy, these unsanitary conditions persisted over multiple days, and the resident confirmed that the bathroom had not been cleaned. Housekeeping staff acknowledged inconsistencies in cleaning due to staffing issues and unfamiliarity with the specific hall. Facility documents confirmed that daily cleaning and disinfection of toilets and handrails were required but not consistently performed.
Failure to Provide Appropriate Bed for Resident with Uncommon Height
Penalty
Summary
The facility failed to provide a safe, comfortable, and homelike environment for a resident whose physical size required special accommodation. Upon admission, the resident's height (6 feet 8 inches) and weight (337 pounds) were documented in both the hospital history and the nurse handoff report. Despite this information, the facility did not have the appropriate bed or equipment available to accommodate the resident's height at the time of admission. Instead, staff improvised by removing the footboard from a standard bed, strapping a piano bench to the foot of the bed, and using a chair to secure the bench in place. The mattress was shifted down, and pillows were used to fill the gap at the head of the bed. The resident reported being told to sleep in a recliner, which he declined, leading staff to modify the bed as described. Staff interviews confirmed that while a wide bed extension was available, there was no extension piece to add length for the resident's height upon arrival. The necessary equipment to properly accommodate the resident was not provided until the following day. Staff also indicated that the admission process would have been different had they been aware of the resident's uncommon height in advance.
Oxygen Removal Leads to Resident Hypoxia
Penalty
Summary
A staff member at the facility removed a resident's oxygen during the admission process to obtain the resident's weight, despite knowing the oxygen was necessary to maintain the resident's oxygen levels. This action led to the resident showing signs of hypoxia, including nausea and vomiting, before the oxygen was replaced. The incident involved a resident who was admitted to the facility and required seven liters of oxygen, which was not available in a portable form at the time of the incident. Interviews with staff members revealed that the removal of the oxygen was not a willful act of abuse, but rather a result of inadequate preparation and resources. Staff member E, who was responsible for obtaining the resident's weight, reported that the room was not set up with the necessary supplies, such as a portable oxygen cylinder, and that the available portable cylinders could not meet the resident's seven-liter requirement. Staff members expressed that it was common knowledge not to remove a resident's oxygen during care, indicating a lapse in adherence to this protocol. The facility's policy defines neglect as the failure to provide necessary goods and services to avoid physical harm, which aligns with the events described in the report.
Failure to Report Neglect Incident
Penalty
Summary
The facility failed to report an incident of neglect involving a resident whose oxygen was removed during the admission process, leading to symptoms of hypoxia. The resident, who was admitted to the facility, had their oxygen removed while being wheeled down the hallway to obtain an admission weight, resulting in nausea and vomiting. This incident was not reported to the State Survey Agency within the required 24-hour timeframe, nor was a follow-up investigation reported within 5 working days. Interviews with staff members revealed a lack of clarity and communication regarding the reporting of neglect. Staff member E reported the incident to staff member G, who then informed staff member H. However, staff members A and B did not believe the event needed to be reported to the State Survey Agency, as they did not consider it a willful act of abuse. The facility's policy on abuse and neglect defines neglect as the failure to provide necessary goods and services to avoid harm, which was not adhered to in this case.
Failure to Provide Adequate Respiratory Services on Admission
Penalty
Summary
The facility failed to ensure that a resident received appropriate respiratory services upon admission, which resulted in neglect of care. The resident, who had a primary diagnosis of COPD, was admitted without the necessary physician orders and equipment for their respiratory needs. During the admission process, a staff member removed the resident's oxygen while obtaining an admission weight, leading to the resident showing signs of hypoxia, including nausea and vomiting. Staff members involved in the incident were not adequately informed or prepared for the resident's specific respiratory care needs. One staff member, who was unfamiliar with the resident, attempted to obtain a weight and vitals but encountered issues with the resident's oxygen saturation. The staff member noted that the room was not set up with the necessary supplies, such as a portable oxygen cylinder, and was unable to find a cylinder that could meet the resident's seven-liter oxygen requirement. This lack of preparation and communication contributed to the resident's distress. The chaotic environment on the day of admission further exacerbated the situation. Staff members were overwhelmed with multiple admissions and medication passes, leading to a lack of proper communication and documentation. The facility's policy required that the attending physician provide necessary information for immediate care, but this was not adequately followed, resulting in the resident's compromised condition during the admission process.
Failure to Provide Appropriate Respiratory Care and Follow Physician Orders
Penalty
Summary
The facility failed to provide appropriate respiratory care for a newly admitted resident who was on a high rate of oxygen. During the admission process, a staff member removed the resident's oxygen while transporting them to obtain an admission weight, resulting in the resident showing signs of hypoxia, including nausea and vomiting. The resident's electronic health record (EHR) lacked documentation of oxygen saturation readings and an admission nursing note, indicating a failure in proper record-keeping and monitoring. Interviews with staff members revealed a lack of understanding and communication regarding the proper procedures for handling residents requiring high levels of oxygen. Staff members admitted to removing the resident's oxygen and acknowledged the absence of necessary equipment, such as a portable oxygen cylinder, which contributed to the incident. The staff also reported that the day was chaotic, and there was a lack of information about the resident's medical needs due to insufficient communication from the hospital. Further observations showed that the facility did not follow physician orders for other residents receiving oxygen, with discrepancies in the oxygen concentrator settings compared to the prescribed levels. The facility's policies on oxygen administration and admission criteria were not adhered to, leading to potential neglect and adverse effects on residents receiving oxygen services. The report highlights a systemic issue in the facility's handling of respiratory care and documentation during the admission process.
Failure to Protect Resident from Non-Consensual Sexual Contact
Penalty
Summary
The facility failed to protect a resident who could not consent to sexual contact from another resident. On November 3, 2024, a staff member observed a resident in another resident's room with his hands under her covers, touching her. The resident being touched was not capable of consenting to sexual contact due to cognitive impairments, including dementia, impaired orientation, forgetfulness, confusion, poor recall, and impaired decision-making. The resident who initiated the contact was aware of his actions but had impulse control issues and a history of hypersexual behavior. The incident on November 3, 2024, was not the first occurrence between these two residents. An earlier incident on May 13, 2024, involved the same resident placing his hand on the other resident's breast in the hallway. Following the May incident, the facility had placed the resident on medication to decrease libido and increased staff supervision. However, the one-to-one observation was discontinued after the resident showed no further hypersexual behaviors. Despite these measures, the resident was able to enter the other resident's room and engage in inappropriate contact again. The facility's policies on abuse and neglect, as well as identifying types of abuse, clearly define sexual abuse as non-consensual sexual contact of any type with a resident. The facility's failure to maintain adequate supervision and protection for the resident who could not consent to sexual contact resulted in a deficiency. The facility's documentation and interviews with staff members revealed that the resident who initiated the contact had a history of inappropriate sexual behavior, yet the measures in place were insufficient to prevent the recurrence of such incidents.
Failure to Protect Resident from Unwanted Sexual Advances
Penalty
Summary
The facility failed to implement care plan interventions to protect a resident from unwanted sexual advances or abuse by another resident. This deficiency involved a resident who was subjected to inappropriate sexual behavior by a male resident on two occasions. The first incident occurred when the male resident touched the resident's breast, and the second incident involved the male resident being found in the resident's room with his hand under her bed covers, during which he touched her breasts and vagina. Despite these incidents, no changes were made to the affected resident's care plan to ensure her safety from the male resident, although changes were made to the male resident's care plan. The care plan for the affected resident, revised after the second incident, did not include interventions to protect her from the male resident or instructions for staff on monitoring or removing her from his vicinity.
Expired Medications and Improper Storage in Medication Rooms and Carts
Penalty
Summary
The facility failed to remove and dispose of expired medications and medical supplies in three medication rooms, three medication carts, and one wound supply cart. Additionally, the facility did not properly store medical supplies, as observed with wound vac supplies on the floor in one medication room. These deficiencies were identified during observations on 3/26/24, where numerous expired medications and medical supplies were found, including items such as Pen needles, Sharp debridement trays, various medications, and wound care supplies with expiration dates ranging from 2016 to early 2024. The presence of these expired items was confirmed in the 400-hall, 300-hall, and 200-hall medication rooms and carts, as well as the wound supply cart. Interviews with staff members revealed that the facility did not conduct the required night shift medication room and cart checks, as audit forms were not available. Staff member B indicated that these audits were likely not performed due to a changeover in management. The facility's policy on Medication Labeling and Storage, revised in February 2023, mandates contacting the dispensing pharmacy for instructions on returning or destroying discontinued, outdated, or deteriorated medications, which was not adhered to in this case.
Failure to Administer Respiratory Treatments According to Professional Standards
Penalty
Summary
The facility failed to administer respiratory treatments in accordance with professional standards of practice for four residents. During an observation, a staff member attempted to administer a nebulizer treatment to a resident using a soiled mask and a chamber containing an earlier dose of medication. The staff member did not clean the equipment properly before attempting to administer the treatment. Additionally, the resident did not have orders to self-administer medications, yet was allowed to start and stop the nebulizer treatment independently. Similar practices were observed for other residents, where staff set up nebulizer treatments and left the residents to complete them on their own without proper supervision or assessment. Interviews with staff revealed inconsistencies in the administration of nebulizer treatments, with some staff stating they stayed in the room while others left the residents unsupervised. Record reviews showed that there were no physician orders or assessments for self-administration for the involved residents, and there was no documentation of vital signs before and after treatments. The facility's policy required staff to remain with residents during treatments and monitor their vital signs, which was not followed in these cases.
Failure to Assess and Document Self-Administration of Medications
Penalty
Summary
The facility failed to ensure residents were assessed and found safe to self-administer their own medications before doing so, and did not document these assessments in the electronic health records (EHRs) for four residents. During an observation, a staff member allowed a resident to self-administer a nebulizer treatment without having a physician's order or an assessment confirming the resident's capability to do so. Interviews with staff revealed that the resident did not have orders to self-administer medications and that the facility did not have the necessary assessments for other residents either. Record reviews showed that one resident had an evaluation indicating they were not capable of self-administration, while two other residents had no assessments documented in their EHRs. The facility's policy required staff to remain with residents during nebulizer treatments, which was not followed. The deficiency was confirmed through interviews, observations, and record reviews, highlighting a failure to comply with the facility's own policies and regulatory requirements for medication administration and resident safety assessments.
Failure to Update Catheter Care Plan
Penalty
Summary
The facility failed to review and revise the comprehensive care plan interventions for catheter care for a resident at risk of infection. During an observation, the resident's room had a strong urine smell, and the catheter tubing was cloudy with white debris. An interview with a staff member revealed that catheters are changed based on the physician's order in the Medication Administration Record. The physician's order indicated that the catheter should be changed for occlusion, leakage, dislodgement, or signs of infection. However, the resident's care plan, last revised over three years ago, stated that the catheter should be changed monthly and was not updated to reflect the physician's order.
Failure to Provide Adequate Repositioning and Incontinence Care
Penalty
Summary
The facility failed to provide adequate incontinence care and repositioning for two dependent residents, which had the potential to increase skin breakdown and cause discomfort. Resident #14 was observed multiple times lying flat on her back with minimal head elevation and reported that staff did not assist her in changing positions despite her care plan indicating the need for repositioning 3-4 times per shift. Staff confirmed that they did not turn her on her sides, only assisting with pulling her up in bed when she slipped down. This lack of repositioning was consistent throughout the observations made on different days and times. Resident #2 was observed sitting in her wheelchair for extended periods without being repositioned or provided with personal hygiene care. She was found with a strong odor of urine, matted eyes, and soaked pants, indicating a lack of incontinence care. Staff confirmed that she had not been repositioned or changed since the morning, despite her care plan requiring repositioning every two hours and monitoring for incontinence. The observations and interviews revealed that the staff did not follow the care plan interventions for repositioning and incontinence care, leading to potential discomfort and risk of skin breakdown for the residents.
Failure to Change Catheter as Ordered
Penalty
Summary
The facility failed to change a resident's catheter, which had the potential to increase the risk of infection. During an observation and interview, the resident's room smelled strongly of urine, and the catheter tubing was cloudy with white debris. The resident could not recall if the catheter had ever been changed. Staff indicated that catheters are changed based on physician orders in the Medication Administration Record. A review of the resident's catheter order and care plan showed that the catheter should be changed monthly and as needed. However, the Treatment Administration Record for the past three months indicated that the catheter had not been changed during this period.
Inadequate Hand Hygiene During Catheter and Wound Care
Penalty
Summary
The facility failed to ensure staff used appropriate hand hygiene during catheter care and wound care for two residents. In the first instance, a staff member performed initial hand hygiene but failed to wash hands between glove changes while providing pericare and catheter care to a resident. The staff member used keys from her pocket to open a package of wipes and did not perform hand hygiene after handling the keys. She also did not wash her hands between changing gloves multiple times during the procedure, which was acknowledged by another staff member as a learning opportunity. In the second instance, two staff members were observed performing wound care on another resident. One staff member removed gloves and handled medical supplies with bare hands before donning new gloves without washing hands in between. This was done despite the facility's policy requiring hand hygiene before and after direct contact with residents, and after handling contaminated equipment. The staff member admitted to not washing hands between glove changes because she believed it was unnecessary since it was the same resident.
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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