Immanuel Skilled Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Kalispell, Montana.
- Location
- 185 Crestline Ave, Kalispell, Montana 59901
- CMS Provider Number
- 275129
- Inspections on file
- 21
- Latest survey
- December 31, 2025
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Immanuel Skilled Care Center during CMS and state inspections, most recent first.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities, as required.
A resident with significant cognitive impairment was restrained in a wheelchair with a seatbelt without a physician's order, proper assessment, or consent. Staff were inconsistent in their understanding of the resident's ability to remove the seatbelt and the rationale for its use, and documentation did not reflect the use of a restraint or a clinical need for it.
The facility failed to implement proper infection control measures, including the absence of enhanced barrier precautions for a resident with a PEG tube, inadequate hand hygiene by staff, and improper handling of clean linens. Additionally, the infection control nurse lacked documentation and tracking for infection surveillance, contributing to the deficiencies identified.
The facility failed to develop comprehensive, person-centered care plans for several residents, resulting in deficiencies in addressing specific medical needs such as pain management, oxygen use, anticoagulant monitoring, and PTSD interventions. Staff acknowledged the issue and mentioned ongoing training efforts.
The facility failed to ensure safe self-administration of medications, as medications were left at the bedside for residents not approved to self-administer. A resident had pills left on her table without authorization, another had medications left on her breakfast tray despite failing the self-administration assessment, and a third resident had eye drops she couldn't open herself. Staff were unaware of proper protocols, leading to unauthorized self-administration.
A facility failed to accurately code a resident's oxygen use on the MDS. The resident was observed using an oxygen concentrator and confirmed continuous use, but the MDS section for oxygen was left blank. A staff member responsible for MDS accuracy acknowledged the error, noting it occurred during a staffing gap, and stated a new MDS staff member was hired to improve accuracy.
The facility failed to complete baseline care plans with necessary signatures and dates, and did not provide copies to two cognitively intact residents. One resident, admitted in January, and another who returned in August, both reported not receiving their care plans. A staff member acknowledged care planning issues and mentioned recent training to address the problem.
A resident was administered oxygen without a physician's order, contrary to the facility's policy and professional standards. The resident, who required oxygen due to respiratory failure, was observed using it without the necessary documentation. Staff interviews confirmed the need for physician's orders for oxygen use, but a review of the resident's records showed no such order was in place.
A facility failed to coordinate care for a resident under hospice, leading to a deficiency. The resident, experiencing cognitive decline and gastric tube issues, relied on hospice for lotion application. However, there was a lack of documentation sharing between hospice and the facility, and updates were only communicated verbally. The facility assumed monthly information sharing, but only received the hospice plan of care after a surveyor request. The resident's care plan did not reflect hospice status, leading to a deficiency in care coordination.
The facility failed to supervise and assess two residents who smoked, allowing them to leave the premises unsupervised and keep smoking paraphernalia in their rooms, contrary to the facility's non-smoking policy. The residents did not sign out as required, and no smoking assessments or physician's orders were documented. Staff interviews revealed a lack of enforcement of the smoking policy.
A facility failed to follow its policy for weighing a resident after readmission. The resident, who was readmitted after a hospital stay, reported infrequent weight checks and desired more frequent weigh-ins. A staff member could not confirm the last weight check, and records showed only one documented weight. The care plan required weekly weights, but this was not adhered to, violating the facility's policy.
A facility failed to ensure proper provider orders for fluid administration during enteral tube feeding and medication administration for a resident. A staff member administered medications and nutrition without specific fluid orders and did not notify the provider for clarification. Medications and enteral nutrition were given four hours late, and orders for flushing the feeding tube were delayed by five days after admission.
A resident with a history of PTSD from serving as a helicopter pilot during the Vietnam War was not provided with trauma-informed care. The resident managed his PTSD by avoiding overwhelming situations, but staff were unaware of his condition due to a missing trauma assessment. Despite annual training, staff did not inquire about the resident's PTSD, and the facility's policy on trauma-informed care was not followed.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt notification and communication regarding an incident that required reporting, as well as the absence of documentation showing that the investigation outcomes were shared with the appropriate external agencies. No additional details about the specific individuals involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Assess and Document Use of Physical Restraint
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraints, specifically by not identifying a seatbelt as a restraint, not assessing the safety or clinical need for its use, and not obtaining a physician's order or consent prior to its application. Observations showed the resident was seated in a wheelchair with a seatbelt in use, and interviews with staff revealed inconsistent knowledge regarding the resident's ability to remove the seatbelt and the rationale for its use. Some staff believed the resident could remove the seatbelt independently, while others stated she could not. Staff were also unaware of the reason for the seatbelt's use, and the resident's family had not been notified or given consent for its placement. Record review indicated there was no physician's order for the seatbelt, and the resident's MDS assessment did not document the use of restraints. The resident was assessed as rarely or never understood, indicating significant cognitive impairment. Occupational therapy evaluation noted the resident had considerable balance impairments and was at high risk for falls, but did not demonstrate a clinical need for a seatbelt at the time of assessment. The seatbelt was in use without proper assessment, documentation, or consent, resulting in the resident being restrained to her wheelchair without a clinical rationale.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement proper infection prevention and control measures, as evidenced by several observations and interviews. In one instance, a resident with a PEG tube was not provided with enhanced barrier precautions, such as a gown, mask, or eye protection, during medication administration. The precautions sign was missing from the resident's door, and necessary protective equipment was not available in the precautions cart. Additionally, medications were placed on an unclean surface without a protective barrier, contrary to standard precautions. Staff members were observed not adhering to hand hygiene protocols. For example, a staff member did not sanitize their hands before donning gloves or after doffing them during medication administration. Another staff member failed to perform hand hygiene before entering and after exiting multiple resident rooms while delivering drinks and taking meal orders. These actions were against the facility's infection control policy, which mandates hand hygiene when entering and leaving resident rooms and after removing personal protective equipment. The facility also lacked proper procedures for handling clean linens, as observed when a staff member transported clean clothes without covering them. Furthermore, the infection control nurse admitted to not having documentation or tracking for infection surveillance, despite being responsible for the infection control program. This lack of documentation and adherence to infection control practices contributed to the deficiencies identified during the survey.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop comprehensive, person-centered care plans for several residents, leading to deficiencies in addressing their specific medical needs. Resident #9, who suffers from Fibromyalgia, Rheumatoid Arthritis, and Chronic Pain Syndrome, reported constant pain, yet her care plan lacked focus, goals, or interventions for pain management, including the use of opioid medications or non-pharmacological approaches. Similarly, resident #10, who was observed using oxygen, had no physician's order or care plan interventions for oxygen use. Resident #32, diagnosed with atrial fibrillation and heart failure, was on the anticoagulant Pradaxa, but her care plan did not address the medication or its potential side effects. Resident #53, a Vietnam War veteran with PTSD, had no care plan interventions for trauma-related issues. Additionally, resident #52's care plan was not specific about oxygen flow settings, and resident #100's care plan was inadvertently closed, resulting in the absence of focus or interventions. Staff member B acknowledged the care plans were not comprehensive or person-centered and mentioned ongoing training efforts. The facility's policy requires comprehensive, person-centered care plans with measurable objectives and timetables, but these were not implemented for the residents in question.
Failure to Ensure Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents were safe to self-administer medications, leading to medications being left at the bedside without proper authorization. Resident #48 was observed with a medication cup containing several pills on her bedside table, which she stated were sometimes left for her to take on her own. However, her self-administration assessment indicated that she was not approved to self-administer medications. Similarly, resident #23 was found with a full medicine cup on her breakfast tray, and staff member O admitted to leaving medications for her to take herself, despite resident #23 not passing the self-administration assessment. The IDT had not reviewed the results of her assessment. Resident #9 had a bottle of artificial tears on her bedside table, which she used for dry eyes. However, she was unable to open the bottle herself and required assistance from staff. Staff member I was unaware of the eye drops in resident #9's room, and the facility's self-administration assessment indicated that resident #9 was capable of opening medication containers, which was not the case. The facility's policy required a self-administration assessment and IDT recommendation for residents to self-administer medications, but these procedures were not properly followed for the residents involved.
Inaccurate MDS Coding for Oxygen Use
Penalty
Summary
The facility failed to ensure that oxygen use was accurately coded on a resident's Minimum Data Set (MDS) assessment. During observations and interviews, it was noted that a resident was using an oxygen concentrator set at 2 liters per minute and wearing a nasal cannula. The resident confirmed that she had been on oxygen for quite some time and needed to wear it continuously. However, a review of the resident's Significant Change MDS, with an Assessment Reference Date (ARD) of 8/30/24, revealed that Section O, which pertains to oxygen use, was left blank. A staff member responsible for MDS accuracy acknowledged the oversight and attributed it to a period when the MDS staff member was unavailable, indicating that a new MDS staff member had been hired to address such issues. The facility's document on Resident Assessments emphasized that MDS assessments should consistently reflect information from progress notes, care plans, and resident observations/interviews.
Incomplete Baseline Care Plans and Lack of Resident Copies
Penalty
Summary
The facility failed to ensure that baseline care plans were completed with the necessary staff signatures, titles, dates of completion, and that copies were provided to the residents or their representatives. This deficiency was identified for two residents, both of whom were cognitively intact with a BIMS score of 15. One resident, who had been at the facility since January 2024, reported never receiving a copy of her care plan after admission. Upon review, her baseline care plan was found incomplete in the section requiring staff and resident signatures and dates. Similarly, another resident who returned to the facility in August 2024 after a hospital visit also reported not receiving any care plans, including the baseline care plan. The review of her baseline care plan revealed the same deficiencies in the signature and date section. During an interview, a staff member acknowledged that care planning was an issue and mentioned that baseline care plans were supposed to be completed by the floor nurse upon admission. The staff member also noted that a recent training session had been conducted to address care planning, indicating ongoing efforts to improve the process.
Oxygen Administered Without Physician's Order
Penalty
Summary
The facility failed to meet professional standards of practice by administering oxygen to a resident without a physician's order. During an observation, a resident was found using oxygen at two liters via nasal cannula, and the resident stated it was necessary due to respiratory failure. Interviews with staff confirmed that physician's orders are required for oxygen use, and a review of the resident's physician's orders showed no order for oxygen was present. The facility's policy on oxygen administration also mandates verification of a physician's order, which was not adhered to in this case.
Failure to Coordinate Care with Hospice
Penalty
Summary
The facility failed to coordinate care for a resident who was under hospice care, leading to a deficiency in providing appropriate treatment and care according to orders, resident’s preferences, and goals. The resident, who was experiencing cognitive decline and had a gastric tube, expressed discomfort due to itching and leaking issues with the tube. The resident relied on hospice staff to apply lotion to areas she could not reach, but there was a lack of coordination between the facility and hospice staff. The hospice nurse confirmed that documentation was not shared between hospice and the facility, and updates were only communicated verbally during visits. The facility staff assumed that hospice information was sent monthly, but they only received the hospice plan of care and notes after the State Survey Agency requested them. The resident's care plan, last updated in August, did not reflect her hospice status or the coordination of care between the facility and hospice. The hospice admission packet indicated that care plans and updates should be shared, but this was not done until prompted by the surveyors. This lack of communication and documentation led to the deficiency in coordinating the resident's care with hospice services.
Failure to Supervise and Assess Smoking Residents
Penalty
Summary
The facility failed to adequately assess and supervise residents who smoke, leading to potential safety hazards. Two residents, identified as #53 and #77, were observed leaving the facility to smoke without notifying staff or signing out, as required by the facility's policy. Both residents kept smoking paraphernalia, such as lighters and cigarettes, in their rooms, which is against the facility's non-smoking policy. Resident #53 mentioned that he often walked off the property to smoke, which was exhausting for him, and he was not monitored by staff during these times. Similarly, resident #77, who used an electric wheelchair, also left the property to smoke without supervision or signing out. The care plans for both residents indicated that they were smokers and included goals to prevent injury from unsafe smoking practices. However, the interventions listed, such as instructing residents on smoking risks and the facility's smoking policy, were not effectively implemented. There were no physician's orders or smoking assessments completed for either resident, which further indicates a lack of proper evaluation and monitoring of their smoking habits. Interviews with staff revealed a lack of awareness and enforcement of the facility's non-smoking policy. Staff member A admitted to not knowing what actions would be taken if an incident occurred while the residents were smoking outside. Additionally, the facility failed to provide requested documentation, such as the smoking policy, list of residents who smoke, smoking assessments, and physician's orders, before the survey concluded.
Failure to Document Resident's Weight as Per Policy
Penalty
Summary
The facility failed to adhere to its policy for weighing and documenting a resident's weight at designated intervals following a readmission. A resident, who was readmitted in August 2024 after a hospital stay, reported not having her weight checked frequently and expressed a desire to be weighed more often. During an interview, a staff member was unable to confirm the last time the resident was weighed. A review of the resident's electronic medical record showed only one documented weight on September 1, 2024. The resident's care plan, revised on September 10, 2024, indicated that weights should be recorded weekly. The facility's policy required residents to be weighed upon admission, then the following two days to establish a baseline, followed by weekly weights for four weeks, and then monthly. This policy was not followed for the resident in question.
Deficiency in Enteral Feeding and Medication Administration
Penalty
Summary
The facility failed to ensure proper provider orders were in place for the administration of fluids during enteral tube feeding and medication administration for a resident. During an observation, a staff member verified the placement of the resident's feeding tube and administered medications and nutritional supplements without specific orders for fluid administration. The staff member used her knowledge to administer fluids between medications and before and after tube feeding, but acknowledged that she should have contacted the provider or dietician for clarification since there were no orders in place. Additionally, the staff member administered medications and enteral nutrition four hours after the scheduled time, without notifying the provider for clarification or adjustment of the next administration times. The resident's medication administration record indicated that orders for flushing the feeding tube with water before and after medication and bolus administration were not in place until five days after the resident's admission. This resulted in a failure to adhere to the facility's policy of administering medications within one hour before or after the scheduled time.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to identify and address PTSD, provide trauma-informed care, and meet professional standards for a resident who was a Vietnam War veteran and helicopter pilot. The resident expressed that being around many people could trigger flashbacks, and he managed his PTSD by sometimes eating in his room to avoid overwhelming situations. Despite the resident's history of PTSD, he reported that facility staff had never inquired about his PTSD or experiences, leading to a tearful reaction during an interview. Interviews with staff revealed that a trauma assessment was supposed to be completed upon admission and reviewed annually, but the assessment for this resident was missing. Staff members who worked with the resident were unaware of his PTSD, despite receiving annual online training on PTSD and trauma care. The facility had implemented a PTSD screening process in October 2023, but the resident was overlooked, and no trauma assessment was conducted for him. The facility's policy on trauma-informed and culturally competent care emphasized minimizing re-traumatization and conducting universal screening and assessment, which was not adhered to in this case.
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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