Logan Health - Conrad
Inspection history, citations, penalties and survey trends for this long-term care facility in Conrad, Montana.
- Location
- 805 Sunset Blvd, Conrad, Montana 59425
- CMS Provider Number
- 275119
- Inspections on file
- 18
- Latest survey
- April 28, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Logan Health - Conrad during CMS and state inspections, most recent first.
Several residents reported receiving cold meals, and observations confirmed that food was plated and left in uninsulated carts with doors open for extended periods before being served. Staff acknowledged a lack of knowledge about proper serving temperatures and noted that food trays often sat for 20 to 30 minutes before delivery. Temperature checks at the time of service showed hot foods were consistently below the required 135°F, with some items as low as 104°F, due to prolonged holding times and inadequate equipment.
Surveyors observed multiple instances of expired, undated, and improperly stored food items throughout the facility, including moldy strawberries, expired baking soda, undated produce with signs of spoilage, and unidentifiable frozen meat. Staff interviews revealed inconsistent monitoring and disposal of expired items, and a public area cooler was found in use without temperature logs or a thermometer, despite policy requirements for proper food storage and labeling.
Expired and improperly labeled medications and supplies, including insulin without identifiers or expiration date, as well as expired ointments, dressings, and a suture removal kit, were found in the medication room. Pharmacy and facility staff were responsible for monthly checks, but expired items remained undetected despite these procedures.
The facility did not consistently implement infection control protocols, including failing to post enhanced barrier precaution signage for two residents with a pressure sore and a Foley catheter, not ensuring a coughing staff member wore a mask as required, and not enforcing hand hygiene after handling contaminated laundry, despite clear facility policies and staff awareness.
Two residents experienced distress and frustration when water was served in soft plastic disposable cups instead of hard plastic cups, while other beverages were provided in sturdier containers. Staff interviews revealed that hard plastic cups were available in the kitchen, but nursing staff opted for disposable cups, despite the facility's policy to provide appropriate adaptive equipment to support resident independence.
A resident with a documented diagnosis of bipolar disorder, supported by a current prescription for Aripiprazole, did not have this mental health condition listed on their PASARR. Staff confirmed the diagnosis was present in the medical history and linked to medication orders, but it was not included in the current diagnoses used for the PASARR, and the reason for this omission was unknown.
A resident with multiple chronic conditions was admitted without a baseline care plan being completed within 48 hours, as required by facility policy. The responsible staff member was absent at the time of admission, and no other staff initiated or completed the care plan, resulting in a delay in outlining necessary care instructions for the new admission.
A resident did not receive showers as frequently as indicated in their care plan, which specified a preference for showers twice weekly. Documentation showed the resident received only 12 showers over a 96-day period, with extended gaps between some showers and only one recorded refusal. Staff interviews confirmed inconsistent shower frequency and uncertainty in documentation practices.
A pharmacist did not identify or address the extended use of a PRN psychotropic medication for a resident, as required by facility policy. The resident had an ongoing PRN order for lorazepam without a stop date, and monthly medication regimen reviews over several months failed to note this irregularity, despite policies limiting PRN psychotropic use to 14 days unless properly documented by a physician.
The facility did not have a qualified Dietary Manager, as the Director of Food Services had expired certifications and had not yet completed the necessary testing to renew them. This deficiency had the potential to impact all residents, as the facility's job requirements specified current ServSafe and State Certification in Safe Food Handling and Sanitation.
Surveyors found that two residents' POLST forms were not fully completed, with one lacking a provider's signature and another missing a proper resident or representative signature and date. Staff confirmed that all required fields should be filled out, but could not explain the omissions.
The facility failed to provide adequate supervision on a secure dementia unit, resulting in a resident ingesting odor eliminator and unsecured chemicals. Additionally, two residents experienced falls due to inadequate supervision and improper use of mobility aids. The incidents highlight the need for improved safety protocols and staff training.
The facility failed to ensure an RN was on staff for at least eight consecutive hours a day, seven days a week. A review of the CMS Payroll-based Journal and nursing schedules revealed the absence of RN coverage on multiple days, including a specific instance on 10/29/23. A staff member confirmed the lack of RN coverage without providing a reason.
The facility failed to ensure proper food storage, hygiene, and sanitation practices. Food was stored directly on the floor in the cooler and freezer. A staff member improperly wore a beard cover and did not perform hand hygiene while serving food. Another staff member did not clean a thermometer before and between taking food temperatures.
The facility failed to ensure staff and residents had access to grievance forms, investigate grievances, and maintain evidence of grievance outcomes. Multiple residents reported unresolved complaints and were unaware of the grievance process. Staff interviews revealed inconsistencies in providing and completing grievance forms, and the grievance log was incomplete.
The facility failed to provide palatable food at an appetizing temperature for four residents. Complaints included consistently cold food, repetitive meals, and serving spicy food despite restrictions. Observations confirmed food temperatures below the required 140 degrees Fahrenheit.
The facility failed to provide dignity and respect for two residents by not knocking and announcing themselves before entering rooms. Both residents and their family members expressed frustration over the lack of privacy. Staff members acknowledged the protocol but did not adhere to it, as observed in multiple instances.
The facility failed to assess a resident for self-administration of medications. The resident was observed administering Systane eye drops without a physician's order or proper assessment, despite having moderate cognitive impairment. The facility's policy required such assessments, but none were found for the resident.
The facility failed to support and assist two residents, who were spouses, in their request to share bed space. Despite multiple requests and a maintenance log entry, the facility did not fulfill their request for a double bed or to have their single beds pushed together. Staff interviews revealed a lack of follow-up and completion of the task.
The facility failed to investigate and report an injury of unknown origin for a resident who complained of shoulder pain and had a bruise on the upper arm. The required investigation and root cause analysis were not submitted to the State Survey Agency within the mandated timeline.
The facility failed to revise a resident's care plan after multiple falls, leading to continued injuries. Staff interviews and document reviews revealed that care plans were not updated with new interventions, and the resident's care plan did not include any new measures after several falls.
The facility failed to ensure a resident had access to their hearing aids, despite care plan instructions and requests from the resident's daughter. Staff provided conflicting information about the location and handling of the hearing aids, leading to the resident frequently being without them and experiencing communication difficulties.
The facility failed to address the use of personal refrigerators in resident rooms, leading to potential food safety issues. A resident's refrigerator contained expired and unlabeled food items, and staff interviews revealed inconsistent practices and lack of a clear policy for personal refrigerators.
The facility failed to submit accurate direct care staffing information to CMS, with discrepancies found between the Payroll-based Journal and the facility's nursing schedules. A staff member acknowledged the errors and corrected the data moving forward.
The facility failed to post nurse staffing information daily at the beginning of each shift. Observations revealed incomplete postings for multiple shifts, and a staff member confirmed that nurses complete the postings after their shifts but could not explain the missing information.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to provide food at a safe and appetizing temperature for six of seventeen sampled residents. Multiple residents reported that their meals were often served cold, both in the dining area and in their rooms. Observations confirmed that food was plated, covered, and placed in uninsulated metal carts with the doors left open during the tray assembly process. The carts did not maintain heat effectively, and the doors remained open for extended periods, sometimes up to 15 minutes or longer, before being closed and transported for meal service. Staff interviews revealed a lack of knowledge regarding proper food serving temperatures and acknowledged that food trays could sit for 20 to 30 minutes before being served, especially for residents eating in their rooms. Temperature checks of food items at the time of service showed that hot foods, such as fish sandwiches, chicken sandwiches, fries, pulled pork, and mashed potatoes, were consistently below the facility's policy requirement of 135°F. Recorded temperatures ranged from approximately 104°F to 128°F at the time of service. The facility's own temperature logs indicated that food was cooked to appropriate temperatures but then sat for extended periods—between one hour and one and a half hours—before being served to residents, resulting in significant temperature drops. Staff interviews further confirmed that the facility no longer used a steam table to keep food hot due to staffing issues, and the current process did not ensure that food remained at safe temperatures. Staff also reported that the metal carts used for food delivery were not insulated, contributing to the loss of heat. The facility's policy required hot foods to be held and served at or above 135°F, but this standard was not met during the survey period, as evidenced by both staff statements and direct temperature measurements.
Failure to Properly Store, Label, and Monitor Food Items
Penalty
Summary
The facility failed to store, label, and monitor food in accordance with professional standards, as evidenced by multiple observations of expired, undated, and improperly stored food items in various storage areas. Surveyors found a package of strawberries covered in thick white mold in a refrigerator on the secure unit, and staff interviews revealed that a resident may have placed the strawberries there without staff noticing. In the dry storage area, six boxes of baking soda were found to be expired, and in the walk-in cooler, an open bag of undated Brussel sprouts and a bag of shallots with a use-by date had a white, slimy appearance and brownish liquid at the bottom. Staff acknowledged that all kitchen staff were responsible for checking and disposing of expired items, but these items had not been removed. A small food cooler in a public dining area lacked a thermometer and temperature logs, yet contained various undated food items, including yogurts, cheese snacks, and fruit bowls. Staff stated the cooler was not supposed to be in use but could not explain why it continued to be used. In the kitchen freezer, a plastic bag with unidentifiable frozen meat was found without a label or date, and staff could not confirm its contents. Additional observations included expired yogurt in a medication storage room refrigerator, and in the main dining room freezer, a half-eaten, undated ice cream cake with no patient identifiers, undated ice cream sandwiches, and undated frozen substances in disposable cups. Facility policy required labeling, dating, and monitoring of food items, but these procedures were not consistently followed.
Expired and Unlabeled Medications Found in Medication Room
Penalty
Summary
Expired and improperly labeled items were found in the medication room during an observation, including an open bottle of Humulin R insulin without resident identifiers or an open or expiration date, as well as expired Ayr Saline Nasal gel, A&D ointment, diaper rash ointment, a suture removal kit, and duoderm adhesive dressings. Staff interviews revealed that pharmacy staff are responsible for monthly checks of medication expiration dates, and facility staff are also expected to double-check for expired medications and supplies. Despite these procedures, expired items remained in the medication room, and a staff member responsible for monthly checks was unsure how the expired medications were missed. Facility policy requires pharmacy staff to verify all medication expiration dates and remove expired medications.
Failure to Implement and Enforce Infection Control Measures
Penalty
Summary
The facility failed to implement and maintain proper infection prevention and control measures for residents requiring enhanced barrier precautions. In two cases, residents with conditions necessitating enhanced barrier precautions—one with a Stage III pressure sore and another with a Foley catheter—did not have the required signage posted outside their rooms. There was also no evidence of a PPE supply cart or staff donning extra PPE for the resident with the pressure sore. Staff interviews confirmed awareness that these conditions required enhanced barrier precautions, but the signage and procedures were not consistently followed or implemented. Additionally, a staff member with a persistent cough, reportedly following a recent influenza outbreak, was observed not wearing a mask while coughing in a communal dining area. Multiple staff interviews indicated that this staff member was repeatedly reminded to wear a mask, in accordance with posted facility signage and policy, but did not consistently comply. The facility's posted instructions clearly stated that anyone with illness symptoms should wear a mask, but this was not enforced. Furthermore, a staff member working in the laundry area failed to perform hand hygiene after removing contaminated gown and gloves before entering the clean side of the laundry facility. This was observed by another staff member, who acknowledged the lapse and intended to address it. Facility policies required hand hygiene after handling contaminated laundry, but this protocol was not followed in practice.
Failure to Provide Appropriate Hydration Equipment Causes Resident Distress
Penalty
Summary
The facility failed to provide hydration in non-disposable cups, resulting in two residents experiencing distress and frustration. Observations showed that while lunch beverages such as juice, milk, and hot drinks were served in hard plastic cups, water was consistently provided in clear, soft plastic disposable cups. One resident expressed that using the disposable water cups made her feel as though she was in jail and caused her frustration due to shakiness and difficulty handling the cup. Another resident was observed struggling to grasp the soft plastic cup and was unable to drink from it, leading to visible distress and vocal expressions of frustration. Interviews with staff revealed conflicting accounts regarding the availability of appropriate cups. Dietary staff stated that there were sufficient hard plastic cups available in the kitchen and that nursing staff chose to use disposable cups for convenience. There was mention of a shortage of small hard plastic cups, but alternative sizes were available and could have been provided upon request. The facility's own standard of care policy indicated that residents should be provided with appropriate adaptive equipment to maintain or improve their ability to feed themselves, which was not followed in this instance.
PASARR Documentation Omission for Mental Health Diagnosis
Penalty
Summary
The facility failed to ensure that a resident's diagnosed mental health condition was accurately reflected on their PASARR documentation. Specifically, a review of the resident's physician orders showed that the resident was prescribed Aripiprazole 2 mg daily for bipolar disorder, with the diagnosis documented in the resident's past medical history and H&P. However, the PASARR completed for the resident did not list bipolar disorder as a diagnosis. Staff interviews confirmed that the diagnosis was present in the medical history and associated with a current medication order, but it was not included in the list of current diagnoses used to generate the PASARR, and staff were unable to explain the omission.
Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to implement a baseline care plan within 48 hours of admission for a newly admitted resident. Observation revealed that the resident was experiencing swollen legs with sock indentations and reported discomfort, as well as a need for assistance with dressing, personal hygiene, and meal setup. The resident's medical history included congestive heart failure, diabetes mellitus Type 2, bipolar disorder, hypertension, obesity, and atrial fibrillation. Despite these complex needs, the baseline care plan was not completed within the required timeframe. Record review showed that the baseline care plan was initiated several days after admission and not completed until a week later. During an interview, the staff member responsible for care plans stated that the delay occurred because she was not present at the time of admission and no other staff initiated or completed the plan in her absence. Facility policy requires that a baseline care plan be developed within 48 hours of admission to ensure effective and person-centered care, but this was not followed in this instance.
Failure to Provide Showers According to Resident Preference
Penalty
Summary
A deficiency was identified when a resident did not receive showers according to their stated preference, as documented in their care plan, which indicated a preference for showers twice per week. Review of the resident's shower records over a 96-day period showed the resident received only 12 showers, with significant gaps of 27 and 26 days between some showers. Interviews with staff confirmed that the resident sometimes went a week and a half between showers, and there was uncertainty regarding documentation accuracy. Only one documented refusal was noted during the review period, indicating that missed showers were not due to resident refusal.
Pharmacist Failed to Identify Prolonged PRN Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a licensed pharmacist identified and addressed the prolonged use of an as-needed (PRN) psychotropic medication for a resident. Review of the resident's physician orders showed a PRN order for Lorazepam oral concentrate, to be given every 8 hours as needed for anxiety, with no stop date indicated. The order was active from November 2024 through April 2025. Monthly medication regimen reviews conducted by the pharmacist for December 2024 through March 2025 did not identify any significant irregularities for this resident, despite the ongoing PRN order for a psychotropic medication. During an interview, the pharmacist responsible for the medication regimen reviews stated that she reviews progress notes, vital signs, labs, physician's orders, and assessments, and is aware that psychotropic medications should be minimized and PRN orders are generally limited to 14 days unless otherwise documented by the physician. However, she was unsure how she missed the prolonged PRN lorazepam order for multiple months. Facility policy requires that PRN psychotropic medications be limited to 14 days unless the physician documents a rationale and duration for continued use, which was not present in this case.
Lack of Qualified Dietary Manager
Penalty
Summary
The facility failed to employ a qualified Dietary Manager, as required for the food and nutrition service. During interviews, the Director of Food Services acknowledged that all of his certifications had expired and had been expired for some time. He reported that although he had registered for a certification course, he had not yet taken the test to renew his credentials. Another staff member confirmed that efforts were underway to get the Director certified. Review of the facility's job requirements for the Food Service Director indicated that ServSafe and State Certification in Safe Food Handling and Sanitation were required, with Certified Dietary Manager status preferred. This lack of current certification in the Director of Food Services had the potential to affect all residents in the facility.
Incomplete POLST Forms and Missing Provider Signatures
Penalty
Summary
The facility failed to ensure that Provider Orders for Life Sustaining Treatment (POLST) forms were fully and properly completed for two residents. For one resident, the POLST form indicated a preference for no CPR with selective treatment and was signed by the resident, but lacked the required signature from a physician or advanced practice practitioner. For another resident, the POLST form indicated a preference for comfort-focused treatment with no CPR, but the patient signature section only contained an 'x' and a check mark, with no printed name or date from the resident or their representative. During staff interviews, it was confirmed that POLST forms should be fully completed, including signatures, printed names, and dates from both the resident or their representative and the provider. The staff member interviewed was unable to explain why the forms were incomplete, though facility policy requires that POLST forms be reviewed and signed by a provider upon admission, with copies placed in the patient's chart and properly documented.
Inadequate Supervision and Chemical Safety in Secure Dementia Unit
Penalty
Summary
The facility failed to provide adequate supervision on a secure dementia unit, resulting in a resident ingesting odor eliminator. Staff member R expressed discomfort working alone on the secure care unit, citing safety concerns. Observations revealed that residents were left unsupervised in the dining room for 10 minutes. Staff member N confirmed that the shower room, where the incident occurred, was not locked, and various chemicals were found unsecured in the room. Resident #34, who is severely cognitively impaired, was known to drink anything left unattended, yet the only intervention was a sign in her room reminding her to call staff for a drink. Staff members acknowledged the need for locks on doors and one-on-one care for Resident #34, but these measures were not implemented due to staffing limitations. The SDS binder was also found to be incomplete, lacking information on several chemicals present in the unit. The facility also failed to provide adequate supervision for fall prevention for two residents. Resident #15 was observed ambulating without her walker and using furniture for support, despite her care plan indicating she required supervision and should not have a bedside table to prevent falls. Staff members had conflicting views on her fall risk, and her nursing progress notes documented multiple falls. Additionally, Resident #6 experienced a fall resulting in a head laceration requiring stitches due to the absence of foot pedals on his wheelchair. Staff members were inconsistent in their knowledge of Resident #6's ability to self-propel and the necessity of foot pedals, leading to inadequate fall prevention measures. The facility's failure to secure chemicals and provide adequate supervision resulted in significant safety hazards for residents with cognitive impairments. The lack of proper labeling and storage of chemicals, incomplete SDS information, and insufficient staffing contributed to these deficiencies. The incidents involving Resident #34, Resident #15, and Resident #6 highlight the need for improved safety protocols and staff training to prevent future occurrences.
Failure to Ensure RN Coverage for Eight Consecutive Hours
Penalty
Summary
The facility failed to ensure a registered nurse (RN) was on staff for at least eight consecutive hours a day, seven days a week. This deficiency was identified through a review of the CMS Payroll-based Journal, which showed the facility lacked RN coverage for eight consecutive hours on 39 days between 10/8/23 and 12/31/23. Additionally, the facility's nursing schedules confirmed the absence of RN coverage for eight consecutive hours on 10/29/23. During an interview on 4/23/24, a staff member reviewed the schedule and confirmed that no RN was scheduled on 10/29/23, without providing a reason for the absence.
Deficiencies in Food Storage and Hygiene Practices
Penalty
Summary
The facility failed to ensure proper food storage, hygiene, and sanitation practices in the kitchen. Observations revealed that food was stored directly on the floor in both the cooler and freezer, contrary to standard practice requiring food to be six inches off the floor. Additionally, a staff member improperly wore a beard cover, repeatedly touched his face and beard without performing hand hygiene while serving food. Another staff member failed to clean a thermometer before and between taking the temperatures of different foods on the buffet. These deficiencies were identified through observations, interviews, and record reviews, indicating lapses in adherence to professional standards for food storage and handling.
Failure to Ensure Access to Grievance Process and Proper Documentation
Penalty
Summary
The facility failed to ensure that staff and residents had access to the grievance process forms, were able to complete grievance forms for concerns voiced by residents, investigate grievances, and maintain evidence demonstrating the results of all grievances. This deficiency was observed in three of the 22 sampled residents. Resident #16 reported multiple complaints regarding staffing, food quality, a wound on her ankle, and not receiving ice water or food as ordered. Despite notifying staff and writing letters to the administrator, her concerns were not addressed, and she was unaware of a grievance process or form. Staff interviews revealed that grievance forms were not consistently provided or completed, and some staff members were unaware of where to find the forms. Additionally, the facility's grievance log did not include all reported concerns, and there was no evidence of investigation or follow-up for many grievances. Resident #35 also reported unresolved complaints about a cold room, not receiving a double bed as discussed, and dissatisfaction with the food. She and her husband were unaware of a grievance form or process and relied on floor staff to address their concerns. Staff member V, who was responsible for processing grievances, was unaware of any grievances beyond the two listed in the log and had not received any forms. The facility was in the process of placing grievance boxes with forms after surveyors questioned their location. Another resident and a family member also reported not knowing about the grievance process. The grievance box was found to be inaccessible to residents in wheelchairs, and staff members were generally unaware of the location of grievance forms.
Failure to Provide Palatable and Appetizing Food
Penalty
Summary
The facility failed to provide palatable food at an appetizing temperature for four residents. Resident #16 reported that the food was consistently cold and often not what she ordered, despite voicing her concerns to management. Resident #35 also complained about the food being cold and repetitive. Staff member V confirmed that management receives test trays and completes questionnaires on food quality, but temperature issues persist. Surveyors observed that the food served was not at an appetizing temperature, and resident #16 was served spicy food despite a documented restriction against it. Resident #16 was visibly upset and had to call her husband to bring in food from outside. Resident #10 stated that food was always served late and not hot. Resident #21 also expressed concerns about hot food being served cold. During an observation, resident #33's breakfast was found to be below the required temperature, with eggs at 100 degrees Fahrenheit and potatoes at 90 degrees Fahrenheit. The plate had a cover but no food warmer underneath. According to the CDC, food items served should be at least 140 degrees Fahrenheit or higher.
Failure to Knock Before Entering Resident Rooms
Penalty
Summary
The facility failed to provide dignity and respect for residents by not adhering to the protocol of knocking and announcing themselves before entering resident rooms. This deficiency was observed in the cases of two residents. In the first instance, a staff member entered the room of a resident who was lying in bed and visiting with family members without knocking. The resident expressed frustration over the lack of privacy, and the family member confirmed that staff frequently entered without knocking. Despite acknowledging the protocol, the staff member repeated the action shortly after the initial observation. In the second instance, another resident was lying in bed when a staff member entered the room without knocking. A family member noted that while some staff knocked, most did not, and expressed frustration over the lack of privacy. This behavior was observed again when another staff member entered the same resident's room without knocking or asking for permission. Both staff members acknowledged that they were supposed to knock before entering but failed to do so. The facility's policy on resident rights and responsibilities, which includes the right to privacy, was not followed in these instances.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to assess a resident for self-administration of medications. During an observation, a staff member was seen providing all of a resident's medications, but the resident had a bottle of Systane eye drops on her bedside table. The resident stated she administered the eye drops herself but could not verbalize the correct administration instructions or potential side effects. The staff member confirmed that no residents were allowed to self-administer medications. Further observation showed the resident administering the eye drops incorrectly and dropping the bottle on the floor before placing it back on the table. A review of the resident's records showed no physician's order for the eye drops or for self-administration of medications. The resident had a BIMS score indicating moderate cognitive impairment. The facility's policy required an assessment for self-administration of medications upon admission and quarterly, but no such assessment was found for the resident. The staff member also stated that the resident did not self-administer any medications, contradicting the observations.
Failure to Support Resident Bed Sharing Request
Penalty
Summary
The facility failed to support and assist two residents, who were spouses, in their request to share bed space. The couple had requested either a double bed or to have their single beds pushed together on 2/12/24. Despite multiple requests from the residents, the facility did not fulfill their request. During an observation and interview, the residents expressed their distress over the situation, with one resident becoming emotional and stating there was no reason they should not be allowed to share a bed. The surveyor observed that the single beds were placed in separate sections of the room, preventing the couple from sharing a bed as they wished. The facility's maintenance log showed a request for a wider/longer bed made on 2/12/24, but there was no completion date or comments indicating the task was completed. Interviews with staff revealed that the facility did not have longer or wider beds and the only option was to push the beds together and lock the wheels. However, this task was not completed, and there was no follow-up on the request. Staff members were unaware of why the beds had not been addressed, and no further complaints were received from the residents after the initial request at the care conference.
Failure to Investigate and Report Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate and report findings following an incident of injury of unknown origin for one resident. The incident occurred when the resident complained of pain in the right shoulder, and an assessment revealed redness and a bruise on the left upper arm. The bruise measured approximately 10x6 cm. The resident could not recall what happened and stated she had not fallen. The facility did not submit the complete investigation and root cause analysis to the State Survey Agency within the required five working days. Additionally, a staff member responsible for reporting was unable to locate any findings or documentation of the incident being submitted to the State Survey Agency.
Failure to Revise Care Plan After Multiple Falls
Penalty
Summary
The facility failed to revise a resident care plan to show effective interventions following multiple falls with injury for one resident. During an observation, the resident was seen pacing in the hallway without shoes, wearing regular socks, and had a large bruise on her left eye and forehead. Staff interviews revealed that the resident frequently fell, and the care plans were not updated with new interventions, leading staff to disregard them. Incident reports showed the resident had fallen multiple times, but the care plan had not been revised to include new interventions after these falls. A review of the facility's documents indicated that care plans should be reviewed and revised by each service responsible, and the fall prevention plan of care should be modified after a fall event. However, the resident's care plan, last revised after the most recent fall, did not include any new interventions following the previous falls. This lack of updating and revising the care plan contributed to the resident's continued falls and injuries.
Failure to Ensure Resident Access to Hearing Aids
Penalty
Summary
The facility failed to ensure that a resident had access to their hearing aids for necessary communication. Observations and interviews revealed that the hearing aids were not consistently placed in the resident's ears in the morning, despite requests from the resident's daughter and instructions in the care plan. Staff members provided conflicting information about the location and handling of the hearing aids, with some stating they were kept in the resident's room and others indicating they were stored in the medication room for charging. This inconsistency led to the resident frequently being without their hearing aids, impacting their ability to hear conversations and watch television. Interviews with staff and the resident's family highlighted that the hearing aids were essential for the resident's daily activities, yet they were often not put in until specifically requested by the daughter. The care plan clearly stated that the hearing aids should be placed in the resident's ears in the morning, but this directive was not consistently followed. The failure to adhere to the care plan and ensure the resident had access to their hearing aids resulted in communication difficulties and a diminished quality of life for the resident.
Failure to Address Personal Refrigerator Use and Food Safety
Penalty
Summary
The facility failed to adequately address the use of personal refrigerators in resident rooms, leading to potential food safety issues. During an observation, a resident's refrigerator was found to contain expired food items, including open containers of yogurt and milk, and a dessert dish with unidentified contents. The refrigerator also had a sticky substance on the bottom. The resident was unsure how long the food had been in the refrigerator. Staff interviews revealed that refrigerator temperature checks were documented in the electronic medical record, but no specific policy for personal refrigerators was provided upon request. Staff members indicated they followed a policy from another facility, which required items to be labeled and dated, but this was not adhered to in this case. The deficiency was further highlighted by the lack of a clear policy on personal refrigerators and the inconsistent practice of checking and documenting refrigerator temperatures. Despite staff claims that the refrigerator was checked daily, the presence of expired and unlabeled food items indicated a failure in the implementation of proper infection prevention and control measures. The facility's inability to provide a specific policy for personal refrigerators during the survey further underscored the deficiency in addressing food safety and preventing foodborne illnesses among residents.
Inaccurate Staffing Information Submission to CMS
Penalty
Summary
The facility failed to electronically submit accurate and complete direct care staffing information to CMS. The CMS Payroll-based Journal for the facility indicated concerns for licensed nurse staff on 66 days and a lack of RN coverage for eight consecutive hours each day on 39 days within the specified period. However, a review of the facility's nursing schedules showed that licensed staff were present 24 hours a day, and RN coverage was maintained for eight consecutive hours each day except for one day. These findings were inconsistent with the PBJ submissions. During an interview, a staff member acknowledged the errors in the PBJ data and mentioned that corrections were made moving forward by adding missing job codes to the system.
Failure to Post Nurse Staffing Information Daily
Penalty
Summary
The facility failed to post the nurse staffing information on a daily basis at the beginning of each shift. During an observation on 4/22/24 at 6:30 p.m., it was found that the nurse staffing posting for the morning shift on 4/22/24 had not been filled out. Additionally, the posting for 4/18/24 was incomplete for the evening and night shifts. During an interview on 4/23/24 at 6:44 p.m., a staff member stated that nurses complete the posting after their shift but was unaware of why the postings on 4/18/24 and 4/22/24 were not completed.
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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