Eastern Montana Veterans Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Glendive, Montana.
- Location
- 2000 Montana Ave, Glendive, Montana 59330
- CMS Provider Number
- 275144
- Inspections on file
- 21
- Latest survey
- December 10, 2025
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Eastern Montana Veterans Home during CMS and state inspections, most recent first.
Staff failed to maintain adequate supervision and follow safe handling protocols, resulting in a resident being left unsupervised and sustaining a hip fracture after being pulled from a wheelchair by another resident, and in a separate incident, two residents engaged in a physical altercation due to lack of supervision.
The facility did not conduct or document thorough investigations for incidents involving resident altercations and staff-to-resident verbal abuse. Required interviews with involved parties and witnesses were not completed or documented, and findings submitted to the State Survey Agency were incomplete or inaccurate, lacking supporting evidence and details as required by facility policy.
A resident on a special care unit was left unattended in bed for several hours without necessary ADL care, resulting in pain, distress, and multiple skin injuries. The resident was found with his arm caught between the mattress and footboard, covered in BM, and exhibiting combative behavior. Two CNAs assigned to the unit failed to provide care or notify nursing staff, leading to their termination for neglect.
A resident with dementia, identified as at risk for elopement, exited the facility unsupervised and was later found by police with a head injury after a fall. Despite a wander guard and prior incidents of wandering, staff failed to follow elopement protocols, including conducting a head count after a door alarm. Gaps in staff training and incomplete adherence to policy contributed to the resident's unsupervised exit and subsequent injury.
During an influenza outbreak, two residents who were roommates remained together after one tested positive for flu and the other was not tested, despite one having a high-risk respiratory condition. Key infection control staff were absent, leading to missing and inconsistent documentation of testing, isolation, and infection mapping, and the facility did not follow its own policies for surveillance and transmission-based precautions.
Nursing staff did not follow the facility's elopement policy, resulting in a resident leaving the facility unattended. After a door alarm sounded, a staff member checked the perimeter but did not perform a required head count and was unaware of the full policy procedures. The resident was later found outside by police, and the incident revealed gaps in staff training and knowledge regarding elopement protocols.
The facility did not have an RN on duty for at least eight consecutive hours per day on multiple occasions, with the DON only on call and no staffing waiver in place. This left all residents without immediate RN availability when needed.
Staff failed to follow sanitary food preparation practices, including not covering facial hair, not covering or dating food items in storage, and not maintaining freezer equipment, resulting in uncovered and undated food, ice buildup in the freezer, and improper storage of produce. These actions did not meet facility policies for food safety and personal hygiene.
The facility did not complete or maintain required PASRR Level One documentation for three residents with significant mental health and cognitive diagnoses. For one resident, a new PASRR was not submitted after a convalescent stay exceeded the approved period, and for two other residents, no PASRR forms could be found despite their qualifying conditions. Staff were unaware of or did not follow procedures for PASRR completion as outlined in facility policy.
A resident was not properly assessed or monitored for smoking safety, repeatedly left the facility property to smoke without signing out as required, and did not receive a complete smoking safety evaluation. Staff were aware of the resident's noncompliance with the sign-out policy, and the facility did not provide a sheltered area for smoking or ensure adherence to its own smoking policy.
Two residents had POLST forms in their medical records that were missing the required date next to the provider's signature, making the forms incomplete. Staff interviews revealed that POLST forms are reviewed at admission and annually, but not at every quarterly care conference, and there is no specific nurse assigned to oversee their completion. Facility policy requires advance directives to be obtained and communicated, but these steps were not fully followed.
Two residents experienced unsanitary and unmaintained living conditions, including persistent urine stains and odors in a bathroom and a growing, unrepaired hole in a wall. Housekeeping staff reported daily cleaning assignments, but observations and interviews revealed that deep cleaning and repairs were not performed as required by facility policy.
A resident admitted with an order for supplemental oxygen due to COPD did not have a baseline care plan developed within 48 hours that included instructions for oxygen therapy. Staff interviews revealed confusion about the baseline care plan process and whether oxygen needs were addressed, resulting in a deficiency for not meeting immediate care planning requirements.
A resident experienced significant weight loss and decreased food intake due to skin irritation and pacing, but the care plan was not updated in a timely manner to include interventions addressing these issues. Although a nutritional supplement was ordered, the care plan did not reflect this or provide strategies for the resident's altered nutrition needs.
A resident was subjected to physical and psychosocial abuse by facility staff, resulting in skin injuries and emotional distress. Despite the resident's resistance, staff forcibly transferred her to the dining room, leading to a struggle. The facility's investigation revealed multiple staff involvement but failed to address root causes or prevent future incidents.
A resident's preference to eat meals in her room was disregarded by staff, who insisted she go to the dining room despite her protests. The resident, who was cognitively intact and independent in eating, had personal reasons for avoiding the dining room. Staff members were aware of her preference but took her to the dining room for breakfast, citing safety concerns after a reported fall. Surveillance footage confirmed the resident's resistance to being taken to the dining room, highlighting a failure to respect her right to self-determination.
A resident expressed grief and fear after her husband's death, but the facility failed to update her care plan to address these issues. A staff member provided emotional support but was unaware of the care plan's deficiencies. The social services director position was vacant, and the staff member was temporarily covering the role. The care plan lacked focus on grief, loss, or loneliness.
A resident grieving the recent loss of her spouse did not receive adequate social services support from the facility. Despite expressing fear about a new roommate and showing visible emotional distress, her care plan was not updated to address her grief. A staff member provided emotional support but did not document these interactions, and the facility failed to implement timely interventions to help the resident cope.
Failure to Provide Adequate Supervision and Safe Resident Handling
Penalty
Summary
Staff failed to provide adequate supervision and follow established policies and procedures to maintain resident safety on a secure care unit. On one occasion, two residents were left unsupervised in the dining room when a staff member left to put dishes away in the kitchen, and another staff member left the area to use the restroom. During this period without supervision, one resident pulled another resident's wheelchair, causing the resident to fall to the floor. No staff were present in the immediate area to intervene or prevent the incident, as confirmed by video footage reviewed by facility leadership. The resident who fell was initially assessed and found to have no injuries, but was later discovered to be in significant pain and was transferred to the hospital, where a hip fracture was diagnosed and surgically repaired. The incident revealed that staff did not adhere to the facility's policies regarding supervision and safe resident handling. Staff interviews indicated that there should have been at least two CNAs present for constant supervision, and that staff are expected to have another staff member replace them if they need to leave the unit. However, these protocols were not followed, resulting in a lapse in supervision. Additionally, after the fall, staff manually transferred the injured resident from the floor to a wheelchair without using a gait belt, despite gait belts being available on the unit and required by facility policy for safe transfers. This manual transfer was performed by supporting the resident under the arms and holding the back of his pants, which was not in accordance with the facility's safe handling policy. A separate incident involved a physical altercation between two other residents on the secure care unit, which also occurred when staff supervision was lacking. In this case, a staff member failed to notify a supervisor before leaving for a lunch break, resulting in residents being left unsupervised and leading to a resident-to-resident altercation. Documentation and interviews confirmed that the staff member did not follow instructions for one-to-one supervision, contributing to the occurrence of the incident.
Incomplete Investigation and Documentation of Reported Incidents
Penalty
Summary
The facility failed to conduct and document complete investigations for multiple reported incidents involving residents and staff. Specifically, for an altercation between two residents in the dining room, the facility's documentation was limited to a single paragraph with no supporting evidence, such as interviews with the involved residents, staff, or witnesses. There were also no documented interventions or analysis to prevent recurrence. Additionally, the findings submitted to the State Survey Agency for this incident were inaccurate, referencing unrelated individuals and omitting the actual residents involved. In another incident involving an allegation of staff-to-resident verbal abuse, the facility's investigation was incomplete, lacking details on which residents were interviewed and their responses, as well as missing interviews with staff witnesses. The facility's own policies require thorough documentation, including interviews and written statements from all involved parties, but these procedures were not followed. Staff interviews revealed that documentation practices were inconsistent, with investigation notes being saved as findings without maintaining separate interview records or templates.
Resident Neglected and Left Unattended, Resulting in Injury and Distress
Penalty
Summary
Facility staff failed to provide necessary ADL care to a resident residing on the special care unit, resulting in the resident being left unattended in bed for an extended period. The resident was found lying on his side at the foot of the bed, with his left arm caught between the mattress and footboard, and was observed to be in significant pain and distress, screaming and crying. The resident was covered in bowel movement, as were the bed, floor, and floor mats, and had sustained skin tears and bruising to his left hand, wrist, and hip, with a large dark-colored mark and indentation likely from pressure. The bed was noted to be elevated except at the foot, and the resident was combative during care, resisting staff assistance. Review of staff witness statements and personnel files revealed that the CNAs assigned to the resident did not provide care from approximately 2:00 a.m. to 7:00 a.m., despite being aware of the resident's needs and distress. One CNA reported not feeling comfortable with the resident due to his behavior and did not inform the nurse of the situation, while the other CNA did not perform any cares during this period. Both CNAs were subsequently terminated for neglect. Facility policy defines neglect as the failure to provide necessary goods and services to avoid physical harm, pain, or emotional distress, and includes recurrent failure to provide incontinence care.
Failure to Prevent Elopement and Ensure Resident Safety
Penalty
Summary
A resident with dementia, identified as being at risk for elopement and wandering, exited the facility through the front doors and left the property unsupervised. The resident was able to access a public road and was later found by police at a nearby apartment complex, having sustained a laceration to the forehead after a fall. The incident was reported to the State Survey Agency, and the resident required hospital evaluation and observation for the injuries sustained during the elopement. Facility records indicate that the resident had a history of wandering behaviors, including previous incidents where the resident attempted to leave the facility or triggered door alarms. The resident had been assessed as at risk for elopement and had a wander guard device placed. Despite these interventions, the resident was able to exit the facility undetected. On the day of the incident, a staff member responded to the front door alarm, briefly scanned the perimeter, but did not see any residents outside and did not conduct a head count as required by facility policy. Interviews with staff revealed gaps in training and adherence to elopement protocols. The staff member who responded to the alarm had not read the facility's elopement policy and was not fully oriented to the procedures. Facility policy required a full head count and further action if a resident could not be located, but these steps were not followed. Documentation and communication with law enforcement regarding the incident were incomplete at the time of the survey.
Failure to Maintain Infection Surveillance and Isolation During Influenza Outbreak
Penalty
Summary
The facility failed to maintain an effective system for communicable disease surveillance and infection control during an influenza outbreak. Two residents who were roommates remained in the same room after one tested positive for influenza, while the other was not tested, despite having a primary diagnosis that placed him at higher risk for respiratory complications. There was no documentation of moving either resident to a different room or of testing the second resident for influenza. The infection preventionist and another key staff member were absent during the outbreak, and infection control responsibilities were delegated to other staff, but there were discrepancies and missing documentation regarding resident testing, isolation, and infection mapping. Record reviews revealed that the infection control binder lacked completed tracking and trending for the outbreak period, and the infection mapping for the relevant month was not done. The facility was unable to provide a complete infection control log for the outbreak period, and available lists did not document testing or isolation actions for the two affected residents. Facility policies required surveillance tools and transmission-based precautions, including private room placement or cohorting for residents with influenza, but these measures were not documented as being implemented.
Failure to Train Staff on Elopement Policy Leads to Resident Elopement
Penalty
Summary
Nursing staff failed to follow the facility's elopement policy, resulting in a resident leaving the facility unattended. On the day of the incident, a staff member received a call from the police department notifying them that a resident had been found outside the facility near an apartment complex. A head count was then conducted, revealing the resident was missing. The staff member who responded to the door alarm did not hear the alarm and did not perform a head count after checking the perimeter, as required by facility policy. The staff member was unaware that a head count was necessary and had not read the facility's elopement policy, despite having received orientation at the start of employment. Review of facility documentation confirmed that the elopement policy required a head count and a facility-wide response when a door alarm was triggered without an identified cause. The resident's nursing progress notes and the facility's timeline indicated that the resident exited through the front doors and was not noticed by staff during the initial response to the alarm. The lack of staff knowledge and adherence to the elopement policy directly contributed to the resident's ability to elope from the facility.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for at least eight consecutive hours per day, seven days a week, as required. Review of the licensed nursing schedules for July and September 2024 revealed that on several specific dates, there was no documentation of eight consecutive hours of RN coverage within a twenty-four-hour period. Staff confirmed that on these dates, there were no RN hours recorded, and the director of nursing (DON) was only on call and did not work the required eight consecutive hours. The facility did not have a staffing waiver in place to cover these absences. This deficiency had the potential to affect all residents who required nursing services, as an RN was not immediately available when needed.
Food Safety and Sanitation Deficiencies in Dietary Department
Penalty
Summary
Staff failed to prepare food in a sanitary manner and did not maintain freezer equipment or ensure proper storage of food items. Observations included a staff member with an uncovered mustache and beard working in food preparation areas, and the same staff member later handling food with multiple uncovered skin tears and scabs on his forearms. The walk-in freezer contained a box with a partially open, undated bag of omelets and an opened, undated bag of pork sausages. There was also significant ice buildup under a compressor fan, with a tray placed to catch ice chunks, and boxes of food stored directly below, some with ice chunks stuck to them. The walk-in refrigerator had uncovered heads of lettuce stored in a colander inside a box on a shelf, which remained unaddressed over multiple days. Staff interviews revealed that there was awareness of the need for beard nets for facial hair longer than half an inch, but this was not enforced. Staff also reported that requests for freezer repairs had been made, but the issue persisted, and the practice of chipping away ice chunks was ongoing. Facility policies required food to be covered, labeled, and dated, and for staff to maintain personal hygiene, including keeping facial hair trimmed and clean, but these standards were not met during the survey period.
Failure to Complete and Maintain Required PASRR Documentation
Penalty
Summary
The facility failed to ensure that Pre-Admission Screening and Resident Reviews (PASRRs) were completed and accurate for three of seventeen sampled residents. For one resident with multiple mental health diagnoses, including dementia with behavioral disturbance, anxiety disorder, mood disorder, major depressive disorder, post-traumatic stress disorder, and suicidal ideations, the PASRR on file was a categorical approval for a convalescent stay, which required a new Level One PASRR if the stay exceeded 29 days. Staff were unaware of this requirement and had not submitted a new PASRR Level One as needed. Additionally, two other residents with documented mental health and cognitive conditions, such as emotional shock, hallucinations, mood disorder, depression, PTSD, cognitive communication deficit, and violent behavior, did not have PASRR Level One forms available in their records. Staff confirmed that PASRRs should have been initiated for these residents based on their diagnoses but could not provide the required documentation or explain why the forms were not completed. The facility's own assessment documentation indicated that PASRRs are to be completed to ensure appropriate placement for residents with cognitive disabilities.
Failure to Assess and Monitor Resident Smoking Safety
Penalty
Summary
The facility failed to properly assess and monitor a resident's safety with regard to smoking. The resident reported going outside to smoke four to five times daily, leaving the facility property due to a no smoking policy, and not signing out as required. Despite being aware of the sign-out policy, the resident consistently did not comply, and staff were aware of this noncompliance. The facility did not provide a sheltered area for smokers, and residents were expected to smoke off property without shelter. Staff interviews confirmed that residents were expected to sign out and store their smoking materials in a weatherproof metal container, but these procedures were not consistently followed. Review of the resident's records showed that the required smoking safety assessment was incomplete, with key areas such as cognitive ability, visual acuity, dexterity, and the ability to safely light and extinguish cigarettes left unassessed. Nurse practitioner and physician notes repeatedly identified the resident as an active smoker but did not address or document smoking safety. The facility's policy required physician consultation for safety restrictions and designated smoking areas, but these were not adhered to, and multiple staff failed to follow the policy over several shifts and days.
Incomplete POLST Forms in Medical Records
Penalty
Summary
The facility failed to ensure that POLST (Physician Orders for Life-Sustaining Treatment) forms were completed accurately in the electronic medical records for two of seventeen sampled residents. Specifically, the POLST forms for these residents were missing the required date next to the provider's signature, which is necessary for the validity of the form and the associated physician order. One resident's POLST indicated a preference for CPR and full treatment, while the other indicated no CPR and selective treatment, but both forms lacked the provider's signature date. A hard copy of one resident's POLST form also showed the same omission. Interviews with staff revealed that POLST forms are reviewed by nursing staff during admission and annually at care conferences, but not at every quarterly care conference. There is no designated nurse responsible for overseeing or reviewing the completion of POLST forms for new admissions; this task is typically handled by the admitting nurse. The provider who completes the POLST form is expected to review it. Facility policies require that advance directives, including POLST forms, be obtained, maintained in the medical record, and communicated to the attending physician and during care planning meetings.
Failure to Maintain Clean and Homelike Resident Environment
Penalty
Summary
Surveyors observed that the facility failed to maintain a clean, sanitary, and homelike environment for two residents. One resident's bathroom was found on multiple occasions to have colored stains and dark brown crusted debris around the edges of the toilet and along the walls, as well as a caked and dried dark yellow substance on the floor that appeared to be urine. A strong odor of urine was consistently present. Despite daily cleaning assignments reported by housekeeping staff, the unsanitary conditions persisted over several days, and staff interviews confirmed that deep cleaning had not been performed in the affected bathroom since the staff member began working at the facility. Additionally, another resident's room had a peeling hole in the wall below the heater near the sink, with paint cracking and lifting from the edges. The resident reported that the hole had been present since admission and appeared to be getting larger, with no attempts by staff to repair or cover it. Facility policy required regular cleaning of housekeeping surfaces and prompt cleaning of body fluid spills, but these standards were not met in the observed cases.
Failure to Develop Timely Baseline Care Plan for Oxygen Therapy
Penalty
Summary
The facility failed to develop a baseline care plan with pertinent, condition-specific information to address a resident's needs within 48 hours of admission. Observations showed that the resident was using a nasal cannula connected to an oxygen concentrator set at two liters, as ordered for a respiratory condition related to COPD. However, review of the resident's care plan indicated that the initiation date for supplemental oxygen was not until several days after admission, and there was no evidence that the baseline care plan included the necessary instructions for oxygen therapy within the required 48-hour timeframe. Interviews with staff revealed uncertainty regarding the process for creating and locating the baseline care plan, as well as whether oxygen treatment information was included in the plan. Facility policy requires that a baseline plan of care be developed within 48 hours of admission to address immediate health and safety needs, including essential healthcare information. The lack of timely and complete documentation in the baseline care plan resulted in the deficiency identified by surveyors.
Failure to Timely Update Care Plan for Significant Weight Loss
Penalty
Summary
The facility failed to update the care plan in a timely manner for a resident who experienced significant weight loss. The resident's weight dropped from 143 pounds to 131 pounds, representing an 8.39% loss over 26 days. Despite this notable change, the care plan was not updated to include interventions to address the weight loss until several months later. The resident was observed to be pacing and unable to sit still due to skin irritation, and reported not eating well because of a rash. A nurse practitioner's note confirmed the resident was not eating or drinking adequately due to being focused on the skin condition. Although a nutritional supplement was ordered, the care plan did not reflect this intervention or include strategies to address the resident's decreased intake related to his skin issues and pacing. Staff interviews revealed that each discipline was responsible for updating their respective sections of the care plan, and updates were typically made after the MDS assessment reference date was added. However, the care plan was not promptly revised to address the resident's acute weight loss or the factors contributing to decreased intake. The lack of timely care plan updates resulted in a failure to implement appropriate interventions to address the resident's nutritional needs during the period of significant weight loss.
Resident Abuse and Neglect by Facility Staff
Penalty
Summary
The facility failed to protect a resident from physical and psychosocial abuse by staff, resulting in skin injuries, fear, and sleep disturbances. The incident involved a resident who was forcibly woken up and undressed by a nurse and a CNA, despite her resistance and verbal objections. The staff insisted on taking her to the dining room against her will, leading to a physical struggle that left the resident in shock and fear for several nights. The resident, who was cognitively intact and had a history of osteoarthritis pain, was accustomed to eating in her room. However, staff decided to move her to the dining room for closer monitoring after a fall. Despite the resident's resistance, staff maintained a firm approach, transferring her to a stationary chair to prevent her from leaving the dining room. Surveillance footage confirmed the resident's resistance and the staff's forceful actions. The facility's investigation revealed that multiple staff members were involved in the incident, yet none intervened or reported the abuse immediately. The resident was left with bruises and emotional distress, fearing the return of the staff involved. The facility reported the incident to the State Survey Agency and suspended the staff, but the investigation failed to address the root causes or prevent future occurrences.
Failure to Honor Resident's Dining Preferences
Penalty
Summary
The facility failed to honor a resident's dining preferences, impacting her right to self-determination. The resident, who preferred to eat meals in her room due to personal reasons related to her husband's past experience in the dining room, was forced to go to the dining room against her wishes. This incident occurred when a CNA and a nurse entered her room, woke her up, and insisted she go to the dining room despite her protests. The resident expressed her discomfort and preference to eat in her room, but staff members did not respect her choice. Staff members involved in the incident were aware of the resident's preference to eat in her room due to her emotional distress associated with the dining room environment. Despite this knowledge, staff member I decided to take the resident to the dining room for breakfast, citing concerns about her safety after a reported fall. The staff maintained a firm approach to get the resident ready for breakfast, disregarding her resistance and preference to remain in her room. Surveillance footage confirmed that the resident was taken to the dining room against her will. The footage showed the resident attempting to leave the dining room and resisting staff efforts to transfer her to a stationary chair. The resident's care plan indicated she was cognitively intact and independent in eating, with a preference to eat in her room. The facility's actions violated the resident's right to self-determination and choice, as outlined in her care plan.
Failure to Update Care Plan for Grieving Resident
Penalty
Summary
The facility failed to review and update a comprehensive care plan for a resident who experienced grief and sorrow following the recent death of her husband. During an observation and interview, the resident expressed fear about a new roommate moving in and shared her emotional distress over her husband's passing. The resident noted that facility staff had not addressed her grief or concerns about a new roommate. A staff member acknowledged providing emotional support to the resident but was unaware that the care plan had not been updated. The facility's social services director had recently left, and the staff member was temporarily fulfilling that role. A review of the resident's care plan, last revised two months prior, showed no focus area or interventions related to grief, loss, or loneliness.
Failure to Provide Grief Support to Resident
Penalty
Summary
The facility failed to provide adequate social services to a resident who was grieving the recent loss of her spouse. During an observation and interview, the resident expressed fear about the possibility of a new roommate moving into the room she shared with her late husband. She was visibly emotional, with tears running down her face, and stated that the facility staff had not addressed her concerns or provided any grief support since her husband's passing. The resident's care plan, last revised in August 2024, did not reflect any updates or interventions to address her emotional distress following her husband's death. A staff member acknowledged providing emotional support to the resident but admitted that these interactions were not documented in the electronic medical record (EMR). The staff member also mentioned that the resident's family was involved in her care and intended to consult them about appropriate services for the resident. However, the facility did not timely identify or address the resident's emotional distress, and the social services department failed to implement necessary interventions to help the resident cope with her grief and loneliness.
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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