Faith Lutheran Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Wolf Point, Montana.
- Location
- 1000 6th Ave N, Wolf Point, Montana 59201
- CMS Provider Number
- 275073
- Inspections on file
- 21
- Latest survey
- November 19, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Faith Lutheran Home during CMS and state inspections, most recent first.
A resident arriving from out of town by ambulance was refused admission when staff found her family too intoxicated to complete paperwork. The resident left with her family without a safe discharge plan, and staff did not notify facility management at the time.
A staff member with limited MDS training failed to complete a required re-entry MDS for a resident readmitted from the hospital, resulting in missing assessment data. The staff member was also unaware of how to identify or correct MDS submission errors, leading to multiple reporting issues such as incorrect identifiers, duplicate and late assessments, and resident mismatches, as identified during survey review.
Surveyors found that the facility did not have a certified dietary manager on staff, as the interim manager's certification had expired three years prior and no documentation of advanced training was available. The interim manager was temporarily filling the role after coming out of retirement, and the facility had not yet hired a qualified replacement.
Surveyors found that kitchen and dietary storage areas were not maintained in a sanitary manner, with multiple food items unlabeled and undated, soiled equipment, improper storage of dented cans, and incomplete temperature logs. Staff with facial hair were observed preparing food without required beard or mustache covers, and cleaning schedules were not consistently followed.
A resident with a central IV catheter did not receive care in accordance with enhanced barrier precautions, as staff wore gloves but not gowns during personal care, despite care plan directives. The facility also lacked a current enhanced barrier precautions policy, had recently changed infection prevention staff multiple times, and had not consistently updated infection control and antibiotic stewardship policies.
The facility did not document required screening, education, or obtain signed consent or declination for influenza vaccination for four residents. Staff could not locate the necessary forms, and records lacked evidence of informed consent, contraindication screening, or education prior to vaccine administration, contrary to facility policy.
The facility did not ensure that grievance forms were readily available to residents, did not post the grievance official's contact information, and did not provide a way for residents to file grievances anonymously. A resident reported that anonymity was not possible, and staff confirmed that forms had to be requested and submitted directly to staff, with no secure receptacle for anonymous complaints.
A resident who changed her code status to DNR with comfort care only did not have her care plan updated to reflect this decision, despite clear documentation from medical staff and her expressed wishes. The care plan lacked focus areas, goals, or interventions related to comfort care, even after the resident's condition and preferences were documented and discussed by staff.
A resident receiving regular hemodialysis treatments did not have a physician order for dialysis documented in the medical record, despite ongoing treatments and a care plan indicating dialysis history. The order was not entered until after the deficiency was identified.
The facility did not appoint a licensed Nursing Home Administrator for Montana after the interim Director of Nursing Services' contract negotiations fell through, leaving the position vacant since December 2024. Attempts to have staff share the roles of Nursing Home Administrator and Director of Nursing were unsuccessful due to the additional hours required, potentially affecting all residents.
The facility failed to employ a licensed administrator in Montana, affecting all residents and resulting in non-compliance. The Director of Nursing applied for a license but had not received it, and the facility had not advertised for the position. The Interim CEO confirmed the absence of a licensed administrator since December 2024. Despite multiple attempts by the Certification Bureau to contact the facility regarding the appointment, no response was received.
The facility failed to conduct monthly QAPI meetings and maintain the required committee members, as no meeting was held in February 2025 and a licensed administrator was not employed. This resulted in the QAPI committee lacking necessary staff participation, violating the plan of correction and CMS requirements.
A staff member conducted wound care on a resident in a public area, failing to ensure privacy. The procedure, including wound measurement and ointment application, was performed in the open television room in view of other residents. Interviews revealed that such procedures should not occur in public spaces, and the resident sometimes resists moving to a private room.
A resident with a history of falls did not have fall prevention interventions properly implemented. Despite a care plan update to include tread tape for improved traction, observations revealed the tape was not in place. The resident experienced multiple falls, and the care plan was not revised to address the root causes of these incidents, leading to a deficiency in care.
A resident with a history of falls experienced multiple incidents due to the facility's failure to implement and maintain fall prevention measures. Despite recommendations to use tread tape for improved traction and the need for assistance during transfers, these interventions were not consistently applied. The resident's care plan was not updated following each fall, leading to continued falls and injuries.
The facility failed to manage elopement and fall risks for two residents, leading to one resident leaving the facility unsupervised and another experiencing multiple falls with injuries. Despite indications of risk, proper assessments and care plan updates were not conducted, contributing to repeated incidents.
The facility failed to provide sufficient privacy for residents using shared bathrooms and during personal care. A resident reported a broken bathroom door replaced with a curtain, causing privacy concerns. Additionally, staff did not ensure privacy during personal care, and privacy curtains in four rooms had significant gaps.
The facility failed to provide and consistently document restorative nursing services for three residents, leading to missed opportunities for mobility improvement. Staff interviews and record reviews revealed inconsistencies in completing and documenting restorative exercises, with discrepancies in the electronic medical records and a lack of clear guidelines for staff.
The facility failed to provide food at a palatable temperature for three residents. Observations showed food sitting unattended on the steam table, with temperatures ranging from 112.9 to 125 degrees Fahrenheit. Residents reported that their food was often cold, and staff members were aware of these complaints.
The facility failed to timely update care plans for a resident who eloped multiple times and another who experienced repeated falls with injuries. Staff were unaware of required interventions, and care plans lacked accurate and effective fall prevention strategies.
The facility failed to monitor and control the temperature of personal resident room refrigerators, leading to unsafe food storage conditions for two residents. Observations revealed temperatures in the Danger Zone, and staff interviews indicated confusion and lack of knowledge about proper procedures.
Resident Discharged Without Safe Plan After Admission Refusal
Penalty
Summary
A resident was transported from out of town to the facility via contracted ambulance, with local family members meeting her upon arrival. Upon arrival, staff determined that the family members were too intoxicated to sign admission paperwork, and the staff present refused to accept the resident for admission. The resident subsequently left with her family, and staff did not contact the administrator or other management at the time of the incident. There was no safe discharge plan in place for the resident, who had previously been living with family before her hospitalization and did not have immediate medical concerns such as IV antibiotics or rehab orders.
Failure to Complete and Transmit MDS Assessments Timely and Accurately
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were completed, encoded, and transmitted within the required timeframe for one of fourteen sampled residents. Specifically, a staff member responsible for MDS assessments did not complete a re-entry MDS for a resident who was discharged to the hospital and subsequently readmitted. The staff member reported limited training, having only three days of MDS instruction, and was unaware of the process to correct or add a re-entry MDS. Review of the resident's records confirmed the absence of a required re-entry MDS following the resident's return from the hospital, and the next assessment completed was a quarterly assessment instead. Additionally, the same staff member, who was responsible for submitting the facility's MDS reports, indicated a lack of knowledge regarding the identification and correction of MDS submission errors. Facility records and quality reporting status reports revealed multiple errors, including incorrect Medicare Beneficiary Identifiers, duplicate assessments, late assessments, and resident mismatches. These issues resulted in inaccurate and missing MDS data, as identified during the annual recertification survey.
Lack of Certified Dietary Manager in Food and Nutrition Services
Penalty
Summary
The facility failed to ensure that the dietary manager had completed a certification program approved by a national certifying body or possessed higher education in a related field. During a kitchen observation, there was no documentation available to show advanced training for the dietary manager. Interviews revealed that the current interim dietary manager had come out of retirement to temporarily fill the position after the previous manager left, and her certified dietary manager certification had expired approximately three years prior. There was no certified dietary manager on staff at the time of the survey. These findings were based on direct observation, staff interviews, and record review.
Failure to Maintain Sanitary Kitchen and Food Storage Conditions
Penalty
Summary
Surveyors observed multiple failures to maintain sanitary conditions in the kitchen and dietary storage areas. Food items in the coolers, such as a pitcher of fluid, a gallon of milk, a quart of Half and Half, red jellied products, a bowl of white fluffy substance, and a pan of pasta with sliced meat, were found unlabeled and undated. Large containers of spices were opened and not dated, with some containers appearing soiled and sticky. The inside of the microwave was splattered with food particles, and the meat slicer had visible debris. Dented cans were found stored with undented cans, contrary to staff statements about their handling. Additionally, a bag of chicken breasts thawed in the walk-in cooler was dated from a previous month. Staff members with facial hair were observed in the food preparation area without wearing required beard or mustache covers on multiple occasions. Temperature logs for refrigerators and freezers were incomplete, with several days missing documentation and some dates recorded incorrectly. Staff interviews confirmed lapses in cleaning schedules and knowledge of required practices, contributing to the unsanitary conditions observed throughout the kitchen and storage areas.
Failure to Implement Enhanced Barrier Precautions and Maintain Infection Control Program
Penalty
Summary
The facility failed to ensure that enhanced barrier precautions were properly implemented for a resident with a central IV catheter used for dialysis. During personal care, staff wore gloves but did not use gowns as required, despite the resident's care plan specifying enhanced barrier precautions for the central IV catheter. Observations confirmed that staff did not wear gowns while handling the resident's IV site, and only gloves were available in the resident's room. Staff indicated they believed gowns were unnecessary if the IV insertion site was covered, and there was a lack of accessible personal protective equipment beyond gloves. Additionally, the facility did not maintain an adequate infection surveillance and antibiotic stewardship program. The infection control program had only recently begun using the McGeer criteria, and there was no current enhanced barrier precautions policy in place, only informal guidance. Multiple staff changes in the infection preventionist role occurred over the past year, and some infection control policies had not been reviewed or updated annually as required. Documentation showed gaps in the implementation and oversight of infection prevention and control measures, including incomplete antibiotic stewardship and outdated policies.
Failure to Document Consent and Screening for Influenza Vaccination
Penalty
Summary
The facility failed to ensure proper documentation and procedures were followed for influenza vaccination for four of five sampled residents. Specifically, there was no evidence in the medical records of these residents that screening for medical contraindications was performed, education regarding the risks and benefits of the vaccine was provided, or that informed consent or declination was obtained and documented prior to vaccine administration. Staff interviews confirmed that consent or declination forms could not be located for these residents, despite records showing that the influenza vaccine had been administered. A review of the facility's influenza policy indicated that informed consent, provision of the Vaccine Information Statement (VIS), screening for contraindications, and documentation of refusals or contraindications are required steps prior to vaccination. However, for the residents in question, these steps were not documented as completed. The facility was unable to provide the requested documentation during the survey, resulting in a deficiency related to the administration and documentation of influenza vaccinations.
Failure to Provide Accessible and Anonymous Grievance Process
Penalty
Summary
The facility failed to develop, implement, and operationalize a comprehensive grievance policy and procedure, as well as ensure that grievance information was readily accessible to residents. During interviews and observations, it was found that grievance forms were not readily available in common areas, and there was no posting of the name or contact information for the grievance official. Additionally, there was no secure receptacle for residents to file grievances anonymously. Staff confirmed that residents needed to request grievance forms from staff at the nurse's station or social services, and completed forms were to be handed to staff, with no option for anonymous submission. A review of the facility's grievance policy revealed that written grievances were required to be signed by the resident or the person filing on their behalf, and did not provide for anonymous submissions. A resident reported that while grievance forms were available near the nurse's station, anonymity was not an option, as the facility required the resident's name on the form to address the grievance. These findings demonstrate that the facility did not provide residents with the ability to file grievances anonymously, nor did it make grievance forms and information about the grievance official readily accessible.
Failure to Update Care Plan for Comfort Care Status
Penalty
Summary
The facility failed to revise the care plan for a resident who had recently changed her code status to DNR with comfort care only. Despite clear documentation from the medical provider and dietician, as well as the resident's updated POLST and expressed wishes for comfort care, the care plan dated several weeks after these changes did not include any focus area, goals, or interventions specific to comfort care. Staff interviews confirmed that the resident had declined hospitalization and invasive treatments, opting instead for comfort care, and that the care plan updates were the responsibility of a specific staff member following daily meetings. Medical records showed the resident had been diagnosed with Influenza A and pneumonia, was experiencing poor appetite and low energy, and had made a clear decision, with family present, to receive only comfort care. However, the care plan was not updated to reflect these significant changes in the resident's condition and care preferences, as required by facility policy and regulatory standards.
Lack of Physician Order for Ongoing Dialysis Services
Penalty
Summary
The facility failed to ensure that a resident who required dialysis services had a current physician order for dialysis, as required by professional standards of practice. The resident, who had been receiving dialysis since August 2023 and continued to attend treatments at an off-site dialysis center three times a week, did not have a physician order for dialysis documented in her medical record at the time of review. The absence of a physician order was confirmed during a review of the resident's current orders, which showed no such order until one was entered on 4/23/25, despite the resident's ongoing dialysis treatments. The initial care plan also indicated the resident's dialysis history, but there was no evidence of a physician order for dialysis until well after the resident's admission and ongoing treatments.
Lack of Licensed Nursing Home Administrator
Penalty
Summary
The facility failed to comply with the participation requirements for long-term care facilities by not appointing a licensed Nursing Home Administrator with an active license for the State of Montana. This deficiency arose after the interim Director of Nursing Services, who was expected to renew her contract and assume the administrator role, did not proceed with the contract due to failed negotiations. Her last day of employment was on December 27, 2024, leaving the facility without a licensed Nursing Home Administrator since that time. The report highlights that the facility considered having the interim Chief Executive Officer and another staff member share the roles of Nursing Home Administrator and Director of Nursing, or each filling one of the roles. However, both staff members expressed their unwillingness to work the additional hours required to fulfill both roles simultaneously. The State Operations Manual, Appendix PP, specifies that the Director of Nursing must be full-time, and fulfilling both roles would necessitate working beyond full-time hours. This lack of a licensed administrator may negatively affect all residents at the facility.
Failure to Employ Licensed Administrator
Penalty
Summary
The facility's governing body failed to employ a licensed administrator in the State of Montana, affecting all residents due to the lack of an administrator and resulting in the facility not being in substantial compliance. Staff member A, the Director of Nursing, applied for a license but had not yet received it, and the facility had not advertised for the open administrator position. Staff member B, the Interim Chief Executive Officer, confirmed that the facility had been without a licensed administrator since December 2024, following the departure of the interim Director of Nursing Services, whose contract negotiations fell through. The facility's policy requires a licensed state administrator to manage the facility, but no such individual was listed in the facility's Key Personnel Contact List. The State of Montana's online license verification did not show a license for the appointed administrator. Despite multiple attempts by the Certification Bureau to contact staff member B regarding the appointment of a licensed administrator, no response was received. This ongoing failure to employ a licensed Nursing Home Administrator prevented the facility from complying with federal regulations.
Failure to Conduct Monthly QAPI Meetings and Maintain Required Committee Members
Penalty
Summary
The facility failed to adhere to its plan of correction following a survey conducted on December 3, 2024. Specifically, the Quality Assurance and Performance Improvement (QAPI) committee did not meet monthly as required, with no meeting held in February 2025. This lapse was confirmed during an interview with a staff member who stated that the February meeting was not rescheduled, and the next meeting was planned for the third week of March 2025. A review of the QAPI Committee Minutes from December 2024 and January 2025 showed no documentation of a meeting in February 2025. Additionally, the facility did not have a licensed Nursing Home Administrator employed as of late December 2024, which resulted in the QAPI committee lacking the necessary staff participation as mandated by the Centers for Medicare and Medicaid Services. The facility's plan of correction, dated January 6, 2025, required audits to be presented to the QAPI team monthly to maintain compliance. However, the absence of an administrator meant the committee did not include the required positions, such as the director of nursing services, the medical director or designee, at least three other staff members including an administrator or individual in a leadership role, and the infection preventionist, as outlined in the State Operations Manual, Appendix PP, for F868.
Privacy Breach During Wound Care Procedure
Penalty
Summary
The facility failed to ensure privacy during a medical procedure for a resident in the dementia unit. During an observation, a staff member conducted wound measurement and ointment application on a resident seated in a recliner in the open television room, in full view of two other male residents. The staff member did not ask the resident to move to a private area but instead proceeded with the treatment in the common area. The staff member traced the wound on the resident's heel/lower leg area using a piece of paper and applied ointment to the resident's legs and forearms. Interviews with other staff members indicated that wound care should not be performed in public areas and that the resident sometimes does not cooperate with moving to a private room for treatment.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure that a resident with individualized care needs related to falls had appropriate interventions implemented and maintained. The resident, who had a history of falls and was identified as having potential for falls due to weakness and poor balance, experienced multiple falls in October and November 2024. Despite a nursing note on 10/7/24 indicating a request for tread tape to be placed in the resident's bathroom, the care plan was not updated to reflect this intervention until 10/14/24. However, during an observation on 12/3/24, it was found that the tread tape was not in place as per the care plan update. Following falls on 11/15/24 and 11/17/24, the resident's care plan was not revised to address the root causes of these incidents. The lack of timely updates and implementation of the care plan interventions contributed to the resident's continued risk of falls. The facility's failure to ensure that the care plan was accurately updated and interventions were implemented as planned resulted in a deficiency in providing care that promotes the resident's well-being and prevents further falls.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to implement and maintain fall prevention interventions for a resident with a history of falls and specific care needs. The resident experienced multiple falls in October and November 2024, despite having a care plan that required assistance during transfers and the use of tread tape for improved traction. The care plan was not consistently updated following each fall, and the recommended interventions, such as the placement of tread tape in the bathroom and near the bed, were not implemented. The resident's care plan initially instructed staff to provide assistance during transfers, but it also noted that the resident expected staff to do all the work, which increased the risk of falls. Despite this, the resident was left alone during transfers, leading to falls. The facility's failure to update the care plan and implement the recommended interventions, such as tread tape, contributed to the resident's continued falls and injuries, including skin tears.
Deficiencies in Elopement and Fall Risk Management
Penalty
Summary
The facility failed to identify and manage the elopement risk for a resident, leading to an incident where the resident left the facility unsupervised. Despite previous indications of the resident's desire to leave, such as requests to visit a friend and an attempt to exit the facility, no elopement assessment was conducted. The resident, with a fluctuating BIMS score indicating moderately impaired cognition, managed to leave the facility undetected and was found hours later in a field, suffering from hypothermia and abrasions. The facility's response included applying a wander guard and conducting visual checks, but there were delays in transferring the resident to a more secure unit, and monitoring of the wander guard was not documented until weeks later. The facility also failed to implement and update fall prevention interventions for another resident, who was identified as high risk for falls upon admission. This resident experienced multiple falls, including two with major injuries, without adequate modifications to their care plan. Although some interventions were noted, such as assisting with transfers and keeping a bathroom light on, these were not consistently documented in the care plan. After a significant fall resulting in hospitalization, no new interventions were added to the care plan upon the resident's return. The lack of effective and timely interventions for both elopement and fall risks highlights deficiencies in the facility's ability to prevent accidents and ensure resident safety. The failure to conduct proper assessments, document interventions, and update care plans contributed to repeated incidents and injuries for the residents involved.
Privacy Deficiencies in Shared Bathrooms and During Personal Care
Penalty
Summary
The facility failed to provide sufficient privacy for residents using shared bathrooms and during personal care. Resident #17 reported that the shared bathroom with a neighboring resident had a broken sliding pocket door, which had been replaced with a curtain. This situation had persisted for over a year, causing privacy concerns as the neighboring resident, who had severe cognitive impairment, would often pull the curtain open without knocking. Staff interviews revealed that no maintenance order had been placed for the broken door, and some staff believed the door was unfixable, while others stated it could be repaired by ordering new tracks. Additionally, the facility failed to ensure privacy during personal care for resident #23, as staff member M did not pull the privacy curtain around the bed or close the door while providing care. The resident's roommate was present during this time. Observations also showed that privacy curtains in four rooms had significant gaps, ranging from 32 to 50.5 inches, which compromised visual privacy. Staff interviews indicated that housekeeping was responsible for the curtains, and agency staff were unaware of whom to report the issue to.
Failure to Provide and Document Restorative Nursing Services
Penalty
Summary
The facility failed to provide and consistently document restorative nursing services intended to improve or maintain mobility for three residents. Resident #13, who has receptive and expressive aphasia secondary to cerebral palsy, was observed in a specialized wheelchair with mild muscular spasticity and contractures. Staff interviews revealed inconsistencies in completing and documenting restorative exercises, with missed opportunities for services on multiple dates. The electronic medical record showed a physician's order for daily passive range of motion exercises, but the restorative flow sheet lacked detailed treatment information and a legend to define completion indicators, making it difficult to confirm the extent of missed services. Resident #31, who was discontinued from outpatient occupational therapy, was supposed to continue specific exercises four times per week. However, staff interviews indicated that no restorative exercises were being provided, and there were no guides or directions for staff on the memory care unit. Resident #46 expressed a desire to walk more and noted increased weakness. Despite having an order for range of motion exercises, the electronic medical record showed discrepancies in the frequency of the tasks to be completed. Staff interviews confirmed that restorative care tasks were not consistently completed or documented.
Failure to Provide Food at Palatable Temperature
Penalty
Summary
The facility failed to provide food at a palatable temperature for three of the sampled residents. During an observation, it was noted that food had been sitting unattended on the steam table with lids on, and the temperature of the chicken was recorded at 123.9 degrees Fahrenheit. Additionally, there were no insulated plate bases under the plates, and the food temperatures ranged from 112.9 to 125 degrees Fahrenheit. Staff members acknowledged that the plates were usually warmed before food was placed on them, but this procedure was not followed consistently. Residents reported that their food was often cold, and staff members were aware of these complaints. Interviews with residents revealed consistent dissatisfaction with the temperature of their food. One resident mentioned that the vegetables were consistently cold, and another stated that the hot food was lukewarm. Staff members confirmed that they were aware of the residents' complaints about cold food. The observations and interviews indicate a failure in maintaining food at a palatable temperature, affecting the quality of care provided to the residents.
Failure to Update Care Plans for Elopement and Fall Risk
Penalty
Summary
The facility failed to update a resident care plan in a timely manner for elopement and failed to revise a resident care plan to show effective fall risk interventions following repeated falls with injury. Resident #31 eloped from the facility on three occasions, and although a wander guard was placed on the resident's wrist after the first elopement, the care plan was not updated to reflect these incidents until nearly three months later. Additionally, the care plan inaccurately noted the date the resident was moved to the memory care unit. Staff were also unaware of the requirement for hourly visual wellness checks, indicating a lack of communication and proper documentation. Resident #50, identified as high risk for falls upon admission, experienced four falls, including two with major injuries, within a three-month period. Despite these incidents, the resident's care plan only listed two active fall interventions during this time. Interviews with staff revealed that fall risk assessments and care plan updates were not consistently or promptly conducted, and fall prevention strategies were not adequately documented or implemented. This lack of timely and effective care plan updates contributed to the resident's repeated falls and injuries.
Failure to Monitor and Control Refrigerator Temperatures
Penalty
Summary
The facility failed to monitor and control the temperature of personal resident room refrigerators, leading to unsafe food storage conditions for two residents. During observations, the refrigerator in one resident's room was found to be at 55 degrees Fahrenheit, containing seven cartons of milk. The resident stated that the facility managed the refrigerator temperatures and cleanliness, but a staff member was unsure of the safe temperature range. Another resident's refrigerator was observed at 50 degrees Fahrenheit, which is within the Danger Zone for bacterial growth. The resident also stated that the facility was responsible for cleaning and temperature monitoring. Multiple staff members provided conflicting information about who was responsible for managing the refrigerator temperatures, indicating a lack of clear protocol and accountability. The facility's policy requires that dormitory-sized refrigerators in resident rooms maintain a temperature at or below 41 degrees Fahrenheit and that Environmental Services staff record these temperatures weekly. However, the policy was not followed, as evidenced by the unsafe temperatures observed and the absence of a thermometer in one of the refrigerators. Staff interviews revealed confusion and lack of knowledge about the proper procedures for monitoring and maintaining refrigerator temperatures, further contributing to the deficiency in ensuring food safety for the residents.
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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