Livingston Health & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Livingston, Montana.
- Location
- 510 S 14th St, Livingston, Montana 59047
- CMS Provider Number
- 275047
- Inspections on file
- 23
- Latest survey
- November 18, 2025
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Livingston Health & Rehabilitation Center during CMS and state inspections, most recent first.
Staff failed to thoroughly investigate and address two incidents of neglect, including inadequate bowel and bladder care for several dependent residents and incomplete medication and treatment documentation for over twenty residents. Staff interviews revealed gaps in training on neglect and medication administration, with provided materials focusing only on sexual abuse. Internal quality assurance processes were insufficient, with no formal QAPI meeting held and delayed reporting to the nursing board.
A nurse failed to complete required medication administration and care documentation for 23 residents during a night shift, resulting in missing or late medications and unrecorded treatments. Residents and staff reported concerns about missed doses, and facility records showed numerous incomplete MARs and care tasks, particularly for residents with complex medical needs. The nurse stated she intended to complete documentation later due to a migraine, but this was not communicated to the oncoming staff.
Licensed nursing staff neglected to assess and manage pain and anxiety for a hospice resident in end-of-life transition, resulting in a 17-hour gap between morphine doses and no administration of lorazepam for anxiety. The nurse on duty did not document assessments or interventions for the resident's restlessness, and the lack of care negatively affected the resident's comfort.
A resident suffered a large hematoma and swelling to the left lower extremity after staff performed a manual stand pivot transfer instead of using a hoyer lift as required. The incident was caused by lack of updated care plan information, poor communication between therapy and nursing staff, and failure to ensure the proper transfer equipment was in place.
Facility staff did not submit investigative findings for two residents with injuries of unknown origin within the required timeframe. In both cases, the responsible staff member mistakenly saved rather than sent the reports, resulting in late submission to the State Survey Agency.
A resident's care plan was not updated to reflect changes in transfer ability after new PT documentation indicated transfer goals were discontinued due to pain and lack of participation. The care plan continued to state the resident could transfer with assist of one, despite evidence to the contrary, and the resident later sustained a hematoma likely related to a difficult transfer. Staff interviews confirmed the care plan was not revised as required.
Staff did not consistently use PPE or perform hand hygiene when providing care to residents on enhanced barrier or contact precautions, including during wound care and meal assistance. In several cases, staff were unaware of or did not follow posted precaution signage, and necessary PPE supplies and disposal containers were not available. The facility also lacked proper documentation and procedures to prevent legionella, with missing temperature logs and no flushing of unused toilets.
Surveyors found multiple expired stock medications in the medication cart, including sodium chloride, guaifenesin, various vitamins, aspirin, and stool softener capsules. A staff member stated that auditing for expired medications was a shared responsibility among nursing staff, but expired medications were still present despite facility policy requiring immediate removal and disposal.
A resident who was independent with showering reported feeling unsafe due to a slippery tiled wall that could not be used for support and an emergency pull cord that was not within reach from the shower chair. Staff confirmed the pull cord's placement was not accessible, and the resident stated previous concerns had not been resolved.
A resident's privacy was not maintained during a brief change when a staff member only partially closed the privacy curtain and left the window curtain open, exposing the resident to view from a public patio. The staff member admitted to forgetting to close the window curtain, and the resident expressed concern about being seen.
A resident's room was found to be unclean, with liquid spills, dirt, dust, and debris present over multiple days. The resident expressed frustration about the inability to move his bedside table due to the dirty floor and reported that housekeeping had not cleaned the room all week. Staff confirmed that rooms were not being cleaned daily as required, citing staffing shortages.
Nursing staff did not maintain or follow current physician orders for wound care for two residents, resulting in periods without appropriate orders and the use of unclear or inappropriate dressing protocols. One resident with a heel pressure injury lacked a physician order for several days, while another with surgical incisions received dressing care that did not match the physician's recommendations until orders were clarified.
A resident did not have documentation of receiving or declining a pneumonia vaccine, as required by facility policy. An audit identified missing consents for this and other residents, and review of records confirmed the absence of the necessary immunization review and administration.
Two residents experienced severe weight loss due to the facility's failure to monitor and address their nutritional needs. One resident lost 17% of their body weight over 42 days, while another lost 12.1% over 63 days. The facility did not implement timely dietary interventions, failed to update care plans, and did not provide fortified meals as ordered. Deactivated weight loss alerts further delayed necessary assessments and interventions.
A resident with severe cognitive impairment and chronic pain was inadequately managed by the facility staff, leading to ongoing distress and a decline in her condition. Despite frequent expressions of pain, the staff failed to update her pain management plan or respond effectively to her needs, resulting in significant suffering and reduced quality of life.
The facility failed to maintain sufficient nursing staff and ensure a licensed nurse was always present. During a night shift, an LPN and a CNA left the facility, leaving only one CNA to care for 44 residents. This absence led to inadequate care, with one resident missing medication and others left wet and soiled. Attempts to contact the absent staff were unsuccessful.
The facility's dietary department was understaffed, causing meal service delays and unmet resident preferences. Observations showed meals were served late, with non-dietary staff assisting due to insufficient dietary personnel. Expired nutritional drinks and compromised kitchen cleanliness were noted. Residents experienced significant delays, with some meals served over an hour late, and preferences not followed, leading to meal refusals.
The facility's kitchen and dietary storage areas were found to have multiple sanitation issues, including soiled equipment, improperly stored and labeled food, and expired items, increasing the risk of foodborne illnesses. Staff interviews revealed a lack of awareness and understaffing, contributing to the deficiencies. Additionally, reviews of sanitation and food temperature logs showed lapses in maintaining proper protocols.
A facility failed to report an allegation of neglect within 24 hours when an LPN and a CNA left their shift, leaving 44 residents without licensed nurse coverage. The incident occurred during a night shift, with only one CNA remaining to care for the residents. Attempts to contact the absent staff were unsuccessful, and the incident was not reported to the State Survey Agency until days later. The facility's investigation was still ongoing.
The facility failed to properly investigate and intervene in cases of resident-to-resident abuse. In one case, two residents involved in a verbal and physical altercation were not kept separated as instructed, leading to further issues. In another case, a resident was placed with a roommate she did not get along with, resulting in frequent verbal altercations and distress. Staff were unaware of necessary interventions, and care plans were not updated.
The facility failed to update care plans for three residents involved in incidents of altercations, weight loss, and pain management. Two residents had a physical altercation, but their care plans were not updated to reflect the incident or necessary interventions. Another resident's care plan was not updated to reflect dietary changes recommended by a dietitian, and it contained multiple inaccuracies and incomplete sections.
A resident was discharged without proper preparation, lacking a finalized home health referral and necessary medications, including fentanyl patches. The discharge transition plan was incomplete, with no documentation of medication quantities or scheduled doses, and the responsible social service staff was unavailable, leading to the Business Office Manager assisting with discharges.
The facility did not provide evidence of investigation or follow-up for two incidents of resident-to-resident verbal abuse. In one case, a resident threatened another, leading to the removal of the threatened resident for safety. In another case, two cognitively impaired residents were separated after a verbal altercation. Despite reporting these incidents to the State Survey Agency, the facility failed to submit investigation findings.
The facility's medication error rate was 15%, exceeding the acceptable threshold of 5%. A staff member administered an incorrect dose of Sodium Chloride to a resident, and another staff member failed to prime insulin pens before administering Insulin Glargine and Insulin Aspart to a resident. These actions violated the facility's medication administration policies.
The facility's dietary department was understaffed, leading to delayed meal service and unmet resident preferences. Observations and interviews showed meals were served late, with residents expressing dissatisfaction. Only five staff members, including the manager, were available, despite the facility's assessment indicating a need for eight. This staffing shortage affected all residents receiving meals, as staff struggled to maintain timely service and address preferences.
A staff member left Cephalexin capsules at a resident's bedside for self-administration without obtaining a physician's order. Upon questioning, the staff member realized the error and observed the resident taking the medication. The resident's medical record did not contain a self-administration order.
A resident with low cognitive function was found on the floor with a major injury, including a pelvic fracture and significant blood loss, requiring hospitalization. The unwitnessed incident was not reported to the State Survey Agency as an unknown injury. A staff member believed it had been reported but it was not.
The facility failed to provide baseline care plan summaries to three residents or their representatives. Interviews revealed that a staff member was unaware of a resident's care plan, while two residents had not participated in care plan discussions. Staff member G noted that social services usually handle care plan meetings and signatures, but no evidence of signed care plans was found in the residents' EHRs.
A facility failed to provide proper wound care for a resident with a Stage 2 pressure injury, missing multiple dressing changes and not applying prescribed materials. Documentation inconsistencies and lack of staff audits or education contributed to the deficiency.
The facility failed to manage the communal resident personal food refrigerator and freezer properly. Staff were uncertain about who was responsible for monitoring, cleaning, and checking temperatures, leading to improperly stored food and discarded groceries. A resident expressed frustration over the loss of her groceries, which were essential for her nutritional needs. Despite a facility policy outlining procedures for food management, these were not adhered to.
Failure to Investigate and Address Neglect and Medication Documentation Deficiencies
Penalty
Summary
Facility staff failed to conduct a thorough investigation and implement comprehensive corrective actions following two separate incidents involving allegations of neglect. On one night shift, multiple dependent residents assigned to a specific staff member were found in the morning heavily soiled with urine and feces, indicating a lack of appropriate bowel and bladder care. On another night shift, a resident reported not receiving morning medications, which led to the discovery that a nurse had failed to document medication and treatment administration for a significant number of residents during her shift. Review of records confirmed that medication and treatment administration records were incomplete, and there was no verification for non-controlled medications using the facility's blister pack system. Interviews with staff revealed inconsistencies and gaps in training related to abuse, neglect, and medication administration. Several staff members reported only receiving a review of the abuse policy, with training content focused on sexual abuse rather than neglect or medication documentation. Some staff could not recall receiving any recent training on these topics, and there was confusion about the applicability and adequacy of the training provided. Documentation provided by the facility supported these accounts, showing that the abuse and neglect training materials were limited in scope and did not address the specific deficiencies identified. Further, the facility's internal processes for investigation and quality assurance were found lacking. While some staff reported informal or ad hoc meetings to discuss the incidents, there was no evidence of a formal QAPI meeting to address the quality-deficient practices or to develop needed corrections. Key staff members were not notified or included in these meetings, and documentation of required notifications to the state nursing board was delayed. No evidence was provided to show that comprehensive education on medication administration and documentation was completed for licensed staff as required.
Failure to Ensure Medication Administration and Documentation Meets Professional Standards
Penalty
Summary
A facility nurse failed to provide nursing services in accordance with professional standards for medication administration and documentation for 23 out of 24 sampled residents. The nurse did not complete required documentation for medication administration, treatments, and monitoring as ordered by physicians during a 12-hour night shift. Multiple residents' Medication Administration Records (MARs) and treatment records were left incomplete, with numerous required tasks such as pain monitoring, psychotropic side effect monitoring, oxygen saturation checks, and medication applications not documented as performed. In some cases, medications were documented as administered in the MAR, but residents reported not receiving them. Interviews with residents and staff revealed concerns about missed or late medications, with one resident specifically stating she did not receive her thyroid medication and had filed a grievance. Staff members reported frequent complaints about the nurse in question, including uncertainty about whether medications had been given. An internal investigation by facility staff confirmed that the nurse had not completed documentation for 21 residents during the shift, and the electronic medical record system highlighted these omissions. The nurse claimed to have completed all required work but intended to enter documentation as late entries due to a migraine, which was not reported to the oncoming nurse. Review of the MARs and facility investigation showed that essential care tasks and medication administrations were not documented for a wide range of residents, including those with complex medical needs such as hospice care, anticoagulation therapy, and enhanced barrier precautions. The lack of documentation made it unclear whether residents received their ordered medications and treatments, and in some cases, residents with cognitive impairment were unable to confirm whether care was provided. The facility's review referenced professional standards for nursing documentation, emphasizing the need for timely, accurate, and comprehensive records, which were not met in this instance.
Failure to Assess and Manage Pain and Anxiety in Hospice Resident
Penalty
Summary
Licensed nursing staff failed to provide necessary services to a hospice resident in end-of-life transition by not adequately assessing and treating pain and anxiety. The resident, who had a history of restlessness and agitation managed with as-needed lorazepam for anxiety and morphine for pain, received only one dose of morphine and no lorazepam during a 12-hour night shift. Documentation confirmed a 17-hour gap between morphine doses, and there was no record of lorazepam administration for anxiety during this period. The nurse on duty was inconsistent in her account of medication administration and did not recognize that the resident's restlessness could be related to pain or anxiety. Review of the medication administration record and nursing progress notes revealed a lack of documentation regarding assessments or interventions for the resident's restlessness, pain, or anxiety during the shift in question. The absence of timely pain and anxiety management negatively affected the resident's comfort, and the facility's investigation corroborated the neglect of care provided to the resident during this period.
Resident Injury Due to Improper Transfer and Communication Breakdown
Penalty
Summary
A resident sustained a significant injury to the left lower extremity, including swelling and bruising described as the size of a tennis ball, after being transferred incorrectly by staff. The incident occurred when staff attempted to transfer the resident from a wheelchair to bed without using the required hoyer lift, instead performing a stand pivot transfer with a gait belt and three staff members present. The transfer was made more difficult because the resident was very weak, and the proper sling for the hoyer lift was not in place. The nurse documented the injury and noted the resident reported an accident had occurred. Review of the resident's care plan showed it was outdated, indicating the resident could transfer with one person assisting, with no updates reflecting the current need for a hoyer lift. Staff interviews revealed confusion and lack of communication between nursing and therapy staff regarding the resident's transfer status. Therapy had used a slider board earlier in the day and did not leave a sling under the resident, which contributed to the improper transfer method being used by nursing staff. The facility's investigation determined the injury likely resulted from this difficult and incorrect transfer.
Failure to Timely Report Investigative Findings for Resident Injuries
Penalty
Summary
Facility staff failed to report investigative findings for reportable events within the required timeframe for two residents who sustained injuries of unknown origin. In the first case, a resident developed a hematoma on the left lower extremity, and although the incident was initially reported to the State Survey Agency, the investigative findings were not submitted until two days after the deadline. In the second case, another resident experienced swelling and bruising to the right hand, and the investigative findings were also reported two days late. Staff member A, responsible for submitting these reports, stated that in both instances he mistakenly pressed the save button instead of the send button in the reporting system and did not realize the error until after the deadline had passed. Additionally, for the second incident, staff member A expressed uncertainty about whether the event should have been reported but ultimately did so as an unknown injury.
Failure to Update Care Plan Following Change in Transfer Ability
Penalty
Summary
The facility failed to update a resident's care plan to accurately reflect the resident's current ability to transfer from a wheelchair to a bed. A facility-reported incident revealed that the resident sustained a hematoma of unknown origin to the left lower extremity, which the facility's investigation determined likely resulted from a difficult transfer. Interviews with staff confirmed that care plans are supposed to be updated when new physical therapy (PT) orders are received, but in this case, the care plan was not revised to reflect the resident's updated transfer status and abilities as documented in PT progress notes. The care plan continued to state that the resident could perform all transfers with assist of one, despite PT documentation indicating that transfer goals had been removed due to the resident's pain and unwillingness to work on transfers. No updates to the care plan regarding transfer status were found after the initial entry.
Failure to Implement Infection Control Practices and Documentation
Penalty
Summary
Staff failed to consistently implement appropriate infection prevention and control practices, particularly regarding the use of personal protective equipment (PPE) and hand hygiene. Multiple staff members did not don required gowns and gloves when providing high-contact care to residents on enhanced barrier precautions (EBP) for wounds or indwelling devices. For example, staff provided personal care, transferred residents, changed dressings, and handled soiled linens without wearing the necessary PPE or performing hand hygiene between glove changes. In some cases, staff were unaware of the current precaution status of residents or did not follow posted EBP signage, and one resident reported that staff did not use PPE during dressing changes for surgical wounds. Staff also failed to follow transmission-based precautions for residents on contact precautions. Observations revealed that staff entered rooms and provided direct care, such as repositioning and transferring, without donning gloves or gowns as required. In one instance, a resident with a contact precaution sign for pink eye reported that staff never wore PPE, and there was no PPE cart or appropriate disposal containers available. Staff interviews confirmed inconsistent understanding and application of PPE protocols for residents with infectious conditions. Hand hygiene practices were deficient during meal assistance, as staff were observed feeding multiple residents without performing hand hygiene between residents or after touching food items. Additionally, the facility did not maintain adequate documentation or procedures to prevent legionella growth, such as flushing unused toilets or maintaining complete temperature logs. Staff were unaware of specific protocols for legionella prevention, and there were missing records for several months, especially in unused areas of the facility.
Expired Stock Medications Not Removed from Medication Cart
Penalty
Summary
Surveyors observed that expired stock medications were present in the medication cart, including bottles of sodium chloride, guaifenesin, vitamin B-6, folic acid, enteric coated aspirin, vitamin B-12, aspirin, stool softener capsules, and vitamin A, all with expiration dates that had already passed. During an interview, a staff member indicated that the responsibility for auditing expired stock medications was shared among herself and the nursing staff. Review of the facility's policy confirmed that outdated, contaminated, discontinued, or deteriorated medications are to be immediately removed from stock and disposed of according to established procedures. Despite this policy, expired medications remained accessible in the medication cart at the time of the survey.
Inaccessible Emergency Pull Cord and Unsafe Shower Environment
Penalty
Summary
The facility failed to provide a safe environment in the shower room for one resident who was independent with showering. The resident reported feeling unsafe due to a slippery tiled wall that was too thick to grasp for support and expressed concern about the location of the emergency pull string station, which was situated on the other side of the half tiled wall and not within reach from the shower chair. The resident stated she had previously reported these concerns to management but felt that no resolution had been provided. Staff interviews and observations confirmed that the placement of the pull cord station was not accessible to residents while showering, supporting the resident's concerns about safety in the shower room.
Failure to Ensure Resident Privacy During Personal Care
Penalty
Summary
The facility failed to ensure resident privacy during personal care for one resident. On two separate occasions, a resident was observed lying in bed near a window that faced a public patio area. During a brief change, a staff member only partially closed the privacy curtain and did not close the window curtain, resulting in the resident's backside being exposed and visible from the outside patio. The staff member later acknowledged forgetting to close the window curtain. The resident expressed concern about the possibility of being seen from outside during the care activity.
Failure to Maintain Clean and Safe Resident Living Area
Penalty
Summary
A deficiency was identified when a resident's living area was observed to be unclean and not maintained in a safe, comfortable, or homelike manner. During two separate observations, the resident's room had multiple areas with liquid spills, dried dirt, dust, and debris, including treatment syringe caps, a wrapped piece of candy, and dust bunnies entangled with cables. The resident reported frustration with the condition of the room, specifically noting difficulty moving his bedside table due to the dirt on the floor. The resident also stated that housekeeping had not been in his room all week, despite his expectation of regular cleaning. Staff interviews revealed that only one staff member was responsible for cleaning rooms during the week, with two additional staff available only on weekends. The staff member confirmed that resident rooms should be cleaned daily but acknowledged that, due to staffing shortages, rooms were only being cleaned every other day. The lack of adequate cleaning and maintenance directly contributed to the resident's dissatisfaction and the unclean state of the living environment.
Failure to Maintain and Follow Current Physician Orders for Wound Care
Penalty
Summary
The facility failed to ensure that physician orders for wound care were completed, current, and followed by nursing staff for two residents. For one resident with a left heel deep tissue injury, there was no physician order in place for a period of several days, and staff were unable to explain the absence of the order. During this time, the resident's stable eschar was left open to air, and offloading with pillow boots continued, but the lack of a documented order meant that care was not guided by current physician instructions. For another resident with bilateral below-the-knee amputation surgical incisions, the physician order for dressing changes was found to be vague and required clarification. Staff used various dressings, including ace wraps, which were later determined to be inappropriate for the surgical incisions. The physician's specific recommendations for wound care were documented in a progress note but were not reflected in the active orders until several days later, resulting in dressing changes that did not align with the intended treatment plan.
Failure to Review and Administer Required Immunizations
Penalty
Summary
The facility failed to ensure that immunizations were reviewed and administered for one of twenty-four sampled residents. During an interview, a staff member reported that an audit revealed missing consents for several residents, including the affected individual. Review of the resident's electronic health record and the State of Montana Official Immunization Record showed no documentation of pneumonia vaccines being administered or declined for this resident. The facility's policy requires pneumococcal vaccination upon admission after review, with repeated vaccination per CDC guidelines, but this was not followed for the resident in question.
Failure to Address Severe Weight Loss in Residents
Penalty
Summary
The facility failed to adequately monitor and address significant weight loss in two residents, leading to severe health deficiencies. Resident #47 experienced a severe weight loss of 17% over 42 days, with inadequate monitoring and lack of timely interventions. The resident was not weighed regularly, and despite a significant weight loss, no dietary changes or supplements were introduced. The care plan lacked any nutritional interventions, and the resident continued to lose weight until discharge. Resident #71 also suffered from severe weight loss, losing 12.1% of her body weight over 63 days. The care plan was not updated to reflect necessary dietary changes, and there was a significant delay in implementing the dietitian's recommendations. The resident's pain and inadequate food intake were not properly evaluated, and the facility failed to provide fortified meals as ordered by the physician. The weight loss alerts were deactivated, preventing timely assessments and interventions by the dietitian. The facility's inaction and lack of timely response to the residents' nutritional needs resulted in severe weight loss and inadequate care. The failure to monitor weight changes, update care plans, and implement dietary interventions in a timely manner contributed to the deficiencies observed in the care of residents #47 and #71.
Inadequate Pain Management for Cognitively Impaired Resident
Penalty
Summary
The facility nursing staff failed to adequately assess and manage the pain of a resident with a history of severe cognitive impairment and multiple pain-related diagnoses, including a wedge compression fracture and chronic pain. Despite the resident's frequent expressions of pain, such as crying and calling out, the staff did not update the pain management care plan to include non-pharmacological interventions or reassess the effectiveness of the current pain management strategies. The resident's pain management regimen included various medications, but there were inconsistencies in administration and documentation, as evidenced by the resident's continued expressions of pain and the lack of timely response to her needs. The resident's medical records indicated a series of medication changes and discontinuations without clear documentation of the rationale or assessment of their impact on the resident's pain levels. For instance, the hydromorphone was discontinued at the resident's request, despite her severe cognitive impairment, which should have prompted a more thorough evaluation by the staff. Observations and interviews revealed that the resident's pain was not consistently documented, and her cries for help were often ignored or inadequately addressed, leading to a decline in her physical condition and ability to participate in daily activities. Interviews with staff and other residents highlighted a lack of responsiveness to the resident's pain, with reports of the resident being left in pain for extended periods and not being repositioned regularly due to her discomfort. The resident's inability to effectively communicate her pain needs, combined with the staff's failure to proactively manage her pain, resulted in significant distress and a decrease in her quality of life. The facility's inadequate pain management practices were evident in the resident's ongoing suffering and the staff's apparent neglect in addressing her needs.
Insufficient Staffing and Nurse Absence
Penalty
Summary
The facility failed to ensure sufficient nursing staff were available to meet the needs of residents and maintain a licensed nurse on duty at all times. On the night shift of December 25, 2024, the facility was staffed with one licensed nurse and two certified nurse assistants (CNAs). However, the licensed nurse and one agency CNA left the facility together, leaving only one CNA to care for 44 residents. This resulted in a lack of licensed nurse coverage for an unspecified period. Staff member A reported that the nurse documented a refusal of one medication, although the resident wanted to be awakened for her routine anti-anxiety medication. Attempts to contact the nurse and CNA were unsuccessful, and the interim staffing agency was involved in trying to reach them. Staff member I, who worked on the same shift, confirmed that the LPN and CNA left the facility around 12:15 a.m. and returned more than one and a half hours later. During their absence, staff member I attempted to contact the nurse via walkie-talkie but received no response. She also texted the Director of Nursing (DON) but did not receive any feedback. Staff member I was left to manage resident rounds, answer call lights, and ensure resident safety. Upon returning to work on December 27, 2024, staff member I was questioned by another CNA about why many residents were left wet and soiled. Resident #66 expressed a desire to be woken up for her medication at night but could not recall if she had missed any doses.
Dietary Staffing Shortages Lead to Meal Service Delays
Penalty
Summary
The facility failed to provide sufficient staffing in the dietary department, leading to delays in meal service and unmet resident preferences. Observations and interviews revealed that the kitchen was short-staffed, affecting the timeliness and quality of meal service. Meals were served late, with breakfast, lunch, and dinner not being served at the scheduled times. Non-dietary staff had to be called in to assist with meal service, indicating a lack of adequate dietary personnel. Additionally, expired nutritional drinks were found in the kitchen, and the cleanliness of the kitchen was compromised due to staffing shortages. Residents experienced delays in receiving their meals, with some meals being served over an hour past the scheduled time. There were instances where resident preferences were not followed, leading to meal refusals and further delays. Staff interviews confirmed the understaffing issue, with reports of insufficient training and lack of a cleaning schedule. The dietary staffing schedule showed multiple days with inadequate staffing, further contributing to the deficiency in providing timely and satisfactory meal services to residents.
Sanitation and Food Safety Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen and dietary storage areas, leading to an increased risk of foodborne illnesses for all residents receiving food from the kitchen. Observations during the initial tour revealed multiple sanitation issues, including soiled hot chocolate and juice machine nozzles, improperly stored small bowls, and heavily soiled cooler handles. Additionally, numerous food items in the coolers were either unlabeled, undated, or expired, such as souffle cups, mixed fruit, almond milk, nutritional drinks, and cottage cheese. Dented cans of beets were found on a shelf labeled 'use first,' and the cleaning bucket lacked a sanitizing agent. The resident refrigerator was also found with stains and uncleaned spills. Interviews with staff members highlighted issues with staffing and awareness of the kitchen's condition. Staff member B was unaware of outdated nutritional drinks and stated that leftover food should be discarded after three days. Staff member C mentioned that dented cans should be returned for credit and noted that staffing was improving but still insufficient at times. Staff member F, who recently started working at the facility, confirmed the kitchen was severely understaffed and was unaware of any cleaning schedule. The review of sanitation bucket chemical results and food temperature logs further indicated lapses in maintaining proper sanitation and food safety protocols.
Failure to Report Neglect and Absence of Licensed Nurse Coverage
Penalty
Summary
The facility failed to report an allegation of resident neglect within 24 hours of the incident, which involved a licensed nurse and a certified nurse assistant leaving the facility during their shift. This left 44 residents without licensed nurse coverage, increasing the risk of harm or negative outcomes. The staffing schedule indicated that the facility was supposed to have one licensed nurse and two certified nurse assistants on duty during the night shift. However, the licensed nurse and one agency CNA left the facility together, leaving only one CNA to care for all the residents. Staff member A was unaware of how long the facility was without licensed nurse coverage and did not know if any residents missed medications. Staff member I confirmed that the LPN and CNA left the facility around 12:15 a.m., taking a walkie-talkie with them and instructing her to use hers if needed. After approximately 30 minutes, staff member I attempted to contact the nurse via walkie-talkie but received no response. The nurse and CNA returned more than 1.5 hours later. During their absence, staff member I tried to manage resident care and safety alone, noting that no residents fell during this time. However, upon returning to work, she was informed that many residents were left wet and soiled. The incident was not reported to the State Survey Agency until several days later, and the facility's investigation was still ongoing at the time of the report.
Failure to Investigate and Intervene in Resident-to-Resident Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation and implement effective interventions following incidents of resident-to-resident abuse. In one case, a resident verbally and physically abused another resident, and although they were initially separated and counseled, staff failed to maintain this separation during meals. Observations revealed that the two residents were seated together at the same dining table, contrary to the instructions given to staff. Interviews with staff indicated a lack of awareness regarding the need to keep these residents apart, and care plans were not updated to reflect the necessary changes to prevent further altercations. In another instance, a resident was moved to a new room to ensure timely medication delivery but was placed with a roommate with whom she did not get along. This led to frequent verbal altercations, particularly over the use of a TV remote control and the presence of an oxygen concentrator. The situation escalated to the point where one resident expressed a desire to give up rather than continue living in such conditions. Despite these ongoing issues, there was no evidence of a comprehensive investigation or effective interventions to address the conflicts between the roommates.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to update care plans in a timely manner for three residents involved in incidents of physical altercations, weight loss, and pain management. Resident #3 and #83 were involved in a resident-to-resident altercation that resulted in verbal and physical abuse. Despite the incident, Resident #83's care plan remained the original baseline care plan from admission and was not updated to address the altercation or the need to keep the residents separated in the dining room. Additionally, the care plan did not reflect that Resident #83 was on a psychotropic medication. Staff members interviewed were unaware of the altercation and the need for care plan updates. Resident #71's care plan was also not updated to reflect changes in dietary needs as recommended by a dietitian. The care plan inaccurately listed the resident's diet and did not include the dietitian's recommendation for a regular dysphasia mechanical soft diet and calorie-dense medication pass. Furthermore, the care plan contained multiple inaccuracies and incomplete sections, such as instructions for weight-bearing activities despite the resident being bed-bound, and unspecified details for blood pressure monitoring, medication side effects, and assistance required for toileting, transfers, and dressing.
Inadequate Discharge Planning and Medication Management
Penalty
Summary
The facility failed to adequately prepare and orient a resident for discharge, resulting in a deficiency. The discharge planning for the resident was incomplete, as evidenced by the lack of a home health referral being finalized prior to discharge. Staff member G indicated that discharge planning should have been completed before the day of discharge, but the social service staff responsible for this task was unavailable, and the Business Office Manager (BOM) was assisting with discharges. The resident was discharged without all necessary medications, specifically the fentanyl pain patches, which were discarded by two nurses instead of being sent home with the resident. The resident's discharge transition plan was incomplete, lacking documentation of the quantity of medications sent home and the next scheduled doses. Although a home health referral form was signed by the physician for post-discharge services, there was no indication that a home health agency was selected or contacted. The facility's discharge transition plan stated that arrangements for home health and other services would be made prior to discharge, but this was not fulfilled, leaving the resident without the necessary support and medications upon returning home.
Failure to Document Investigation of Resident-to-Resident Verbal Abuse
Penalty
Summary
The facility failed to provide evidence of reporting, investigation, and follow-up actions for allegations of resident-to-resident verbal abuse involving four residents. In the first incident, a verbal altercation occurred between two residents, where one resident threatened to kill the other, causing fear and necessitating the removal of the threatened resident from the shared room for safety. Despite the incident being reported to the State Survey Agency, the facility did not provide documentation of the investigation or findings by the end of the survey period. In the second incident, a verbal altercation occurred between two cognitively impaired residents, leading to their separation for safety. Although this incident was also reported to the State Survey Agency, the facility again failed to submit a report of findings for the investigation by the end of the survey period. During an interview, a staff member confirmed that the facility did not submit the required reports for these incidents.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain medication error rates below 5%, resulting in a calculated error rate of 15%. This deficiency affected two residents during medication administration. In one instance, a staff member administered an incorrect dose of Sodium Chloride to a resident. The physician's order was for a two-gram total dose, but the staff member initially dispensed only one gram. Upon questioning by the surveyor, the staff member corrected the error by administering an additional one-gram tablet. In another instance, a staff member failed to properly prime insulin pens before administering Insulin Glargine and Insulin Aspart to a resident. The facility's policy and manufacturer instructions require priming the insulin pen to ensure accurate dosing and remove air bubbles. The staff member did not perform this safety test, which is a critical step in the medication administration process. These actions and inactions contributed to the facility's failure to adhere to its medication administration policies, leading to the noted deficiency.
Dietary Staffing Shortage Leads to Delayed Meal Service
Penalty
Summary
The facility failed to adequately staff the dietary department, which led to delays in meal service and unmet resident preferences. Observations and interviews revealed that meals were consistently served late, with the noon meal on one occasion being served nearly an hour and a half past the scheduled time. Residents expressed dissatisfaction with the late meal service and the lack of attention to their food preferences. Staff interviews confirmed the shortage of dietary personnel, with only five staff members, including the manager, working in the department, despite the facility's assessment indicating a need for eight staff members. The deficiency affected all residents receiving meals from the dietary department, as evidenced by residents waiting in the dining room and in their rooms for meals to be served. Staff members reported assisting the dietary department as much as possible, but the shortage hindered their ability to maintain timely meal service and address resident preferences. The facility's documented mealtimes were not adhered to, and staff were unable to consistently gather and implement resident meal preferences due to the staffing shortfall.
Failure to Obtain Physician's Order for Self-Administration of Medication
Penalty
Summary
The facility failed to obtain a physician's order for medication self-administration before leaving medications at a resident's bedside. During an observation and interview, a staff member left a medicine cup containing two Cephalexin 500 mg capsules on a resident's bedside table for self-administration. When questioned, the staff member acknowledged the mistake and returned to observe the resident taking the medication. A review of the resident's medical record revealed the absence of a medication self-administration order.
Failure to Report Major Injury to State Survey Agency
Penalty
Summary
The facility failed to report a major injury of a resident to the State Survey Agency. The resident was found on the floor in her room by staff, complaining of pain, and was subsequently transported to the hospital. The resident, who had a low cognitive function and was not a reliable reporter, was diagnosed with a pelvic fracture, significant blood loss, and required intravenous fluids, blood transfusions, and evacuation of a large hematoma. The incident, which was unwitnessed and had no reliable source for the cause of the injury, was not reported as an unknown injury. A staff member acknowledged that the injury should have been reported but mistakenly believed it had already been submitted through the reporting portal.
Failure to Provide Baseline Care Plan Summaries
Penalty
Summary
The facility failed to provide residents or their representatives with a summary of their baseline care plan for three of the six residents sampled for baseline care planning. During interviews, a staff member admitted to not knowing the care plan for a resident who had not been in the facility long. Another resident expressed a desire for more therapy to gain strength for discharge but had not participated in a care plan discussion. A third resident acknowledged the benefits of therapy but had not been informed about their care plan. Staff member G mentioned that social services typically invite residents and representatives to care plan meetings and obtain signatures, but there were no signatures or evidence of baseline care plans in the residents' electronic health records (EHR). The absence of signatures and scanned documents in the EHR confirmed the deficiency in providing care plan summaries to the residents or their representatives.
Deficiency in Wound Care Management
Penalty
Summary
The facility failed to provide appropriate wound care for a resident with a Stage 2 pressure injury on the right lower shin. The physician's order required the dressing to be changed every other day with the application of alginate with silver or calcium alginate. However, during an observation, it was noted that the dressing lacked the prescribed materials, and the wound care was missed multiple times in May and June 2024. The facility's documentation did not consistently record the stage of the pressure injury, and there was no comprehensive review to determine if the wound was avoidable or unavoidable. Interviews with staff revealed a lack of audits and education to ensure proper wound care treatments were being performed according to physician orders. The facility also did not have the necessary committee meeting minutes or a comprehensive review of the resident's medical record to evaluate the avoidability of the pressure ulcer, as required by their Skin Integrity policy. This lack of documentation and oversight contributed to the deficiency in wound care management for the resident.
Improper Management of Resident Personal Food Storage
Penalty
Summary
The facility failed to ensure proper management of the communal resident personal food refrigerator and freezer. During an interview and observation, a staff member indicated uncertainty about who was responsible for monitoring the resident personal food refrigerator, including cleaning and temperature checks. The refrigerator and freezer lacked temperature logs, unlike other kitchen appliances in the same room. An observation revealed improperly stored food, such as a piece of fruit wrapped in a paper towel, not in a closed container, and undated. This lack of oversight led to confusion among staff about their responsibilities. A resident expressed frustration over the disposal of her groceries, which she purchased to address specific nutritional deficiencies. She reported that $50 worth of groceries were discarded because staff were unsure of the food's age. Despite attempts to resolve the issue with staff, the resident found no resolution. Interviews with other staff members revealed assumptions that kitchen staff were responsible for managing the resident personal refrigerator, but no one was certain of the assigned duties. A facility document outlined procedures for managing resident food, including temperature monitoring and food labeling, but these were not followed.
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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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