Madison Valley Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Ennis, Montana.
- Location
- 211 N Main St, Ennis, Montana 59729
- CMS Provider Number
- 275136
- Inspections on file
- 15
- Latest survey
- May 14, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Madison Valley Manor during CMS and state inspections, most recent first.
Surveyors identified multiple instances of undated, unlabeled, and expired food items in storage areas and refrigerators, as well as improper storage of open food containers. Staff interviews confirmed inconsistent food inventory audits and lack of adherence to facility policy on food labeling. Additionally, a dusty oscillating fan was used to dry clean dishes without a set cleaning schedule, and a kitchen floor drain was found to be cracked, unsealed, and in disrepair for an extended period, with staff unable to secure timely repairs.
A kitchen freezer was not properly maintained, with the bottom shelves marked 'Do Not Use' due to issues causing freezer burn and a faulty door seal that failed to keep food frozen. Staff reported the freezer was scheduled for replacement but this was delayed, and food was sometimes discarded when staff forgot not to use the affected shelves.
The facility did not complete or document required assessments before using bed rails and a scoop mattress as restraints or assistive devices for three residents. In each case, documentation was missing or incomplete regarding whether the devices limited freedom of movement, if risks and benefits were discussed, and whether residents could remove the devices independently. Ongoing monitoring of these devices was also not consistently performed or documented.
A resident's representative was not notified after the resident sustained a fall with injury, was diagnosed with a UTI, and was started on antibiotics. Nursing notes documented the incidents and treatment changes, but there was no evidence that the representative was informed, contrary to facility policy.
The facility did not implement or make accessible a comprehensive grievance process, failing to post required information, provide accessible grievance forms, or offer a secure method for anonymous submissions. A resident was unaware of how to file a grievance or do so anonymously, and staff confirmed the lack of accessible forms and secure receptacle, contrary to facility policy.
Two residents were inaccurately assessed, with assistive devices such as a scoop mattress and bed rails incorrectly coded as restraints on their MDS assessments. Both residents were able to move and get out of bed independently, and staff confirmed the devices did not restrict their mobility, yet the documentation did not reflect this.
A resident with left-sided paralysis and limited hand mobility was found with bed rails in the up position and was unable to lower them independently. Staff and documentation failed to recognize and record the bed rails as a restraint, and the assessment did not address that the resident could not remove the rails or that they limited movement, contrary to facility policy.
The facility did not ensure competent nursing staff were available to provide timely medication administration and meet residents' needs. A resident and others reported issues with a travel nurse's attitude and care timeliness, and medication records showed that a resident received several medications hours after the scheduled time on multiple occasions, outside the facility's allowed window. The facility relied heavily on travel nurses, and some did not seek help when running late, resulting in late medication passes.
A hospice resident with advanced disease experienced inconsistent and delayed pain management, as staff often waited to administer stronger pain relief like morphine until after less effective medications were tried, despite ongoing pain. Documentation of pain assessments and follow-up was incomplete, and family members had to advocate for appropriate pain control, resulting in unnecessary discomfort.
The facility did not provide infection prevention and control training to temporary agency staff, as revealed through interviews and observations. A traveling CNA and two other traveling employees reported not receiving such training during their orientation. Observations showed improper hand hygiene practices, and there was no documentation of infection control training for these staff members.
A staff member failed to follow standard precautions during personal care of a resident by not sanitizing hands before donning gloves and not changing gloves between dirty and clean tasks. The staff member acknowledged the oversight, which was against the facility's policy requiring hand hygiene and glove changes to prevent cross-contamination.
The facility failed to ensure accurate MDS coding for diagnoses and restraints. One resident's dementia diagnosis was not updated in the MDS, and three other residents had discrepancies in the documentation of bed rails and alarms. Staff interviews confirmed the lack of a reliable process for updating diagnoses and inconsistencies in MDS coding.
The facility failed to update care plans for two residents, one regarding discontinued blood glucose monitoring and wheelchair use, and another regarding the removal of bed rails. Staff interviews and observations confirmed the discrepancies.
The facility failed to implement bed rails and update the care plan for a resident. Observations showed the absence of bed rails despite a physician's order and care plan indicating their use. Staff interviews revealed confusion about the bed rails' presence and lack of an order to discontinue their use.
Deficient Food Storage, Labeling, and Kitchen Sanitation Practices
Penalty
Summary
The facility failed to ensure proper food storage and labeling practices, as evidenced by multiple observations of undated, unlabeled, and expired food items in the dry storage area, walk-in refrigerator, and resident refrigerator. Items such as open bags of pasta, cereal, and chips, as well as expired Jello mix and undated containers of sauces and dairy products, were found. Staff interviews revealed that food inventory audits were intended to be performed monthly, but expired and improperly labeled items were still present. Facility policy required all foods to be covered, labeled, and dated, but this was not consistently followed. Additionally, the facility did not maintain a clean kitchen environment. An oscillating fan, used to blow air on racks of drying dishes, was observed to have visible gray dust on its spokes and back, with no set cleaning schedule in place. Staff acknowledged the need for cleaning but indicated it was only done when noticed and as time allowed. The fan continued to be used in this condition, posing a risk of dust contaminating clean dishes. The kitchen floor drain was also found to be in poor condition, with a damp towel covering it at times and visible cracks and openings around the drain. Staff interviews and documentation confirmed that the drain had been in disrepair for over a year, with a known crack in the pipe and ongoing difficulties in securing repairs. The area around the drain was unsealed, and odors were sometimes noticed, further indicating a lack of proper maintenance and sanitation in the kitchen environment.
Failure to Maintain Freezer in Safe Operating Condition
Penalty
Summary
The facility failed to ensure that one of the kitchen freezers was adequately maintained and in safe operating condition. During observation, the bottom shelves of the kitchen entryway freezer were marked with cardboard signs stating 'Do Not Use,' yet food items were stored on all other shelves. Staff interviews revealed that the freezer was scheduled for replacement but this had been delayed due to planned kitchen renovations. Staff also reported that the bottom shelf caused freezer burn to food items, leading to food being discarded when staff forgot not to use those shelves. Additionally, there were issues with the freezer door seal, which failed to maintain the frozen state of foods placed on the bottom shelves. Review of the FDA Food Code confirmed that equipment components such as doors and seals should be kept intact and adjusted according to manufacturer specifications, and that corrective action should be taken if equipment fails to maintain proper storage conditions.
Failure to Assess and Document Use of Restraints and Assistive Devices
Penalty
Summary
The facility failed to perform and document complete resident assessments prior to the use of physical restraints or assistive devices that could be considered restraints for several residents. In one case, a resident with left-sided paralysis and limited hand mobility had upper bed rails in place, which he could not lower independently. Staff and the resident indicated the bed rails were used to prevent falls and assist with mobility, but documentation did not show whether the bed rails met the criteria for a restraint or if risks and benefits were discussed with the resident or representative. The assessments also failed to indicate if the resident could remove the bed rails independently, despite staff statements that the rails restricted his ability to get out of bed. Another resident was observed using a scoop mattress, which she stated did not restrict her movement and was used to assist with transfers and positioning due to poor core control. However, the facility did not complete or document an assessment prior to the initial use of the scoop mattress, nor did they provide ongoing monitoring of its use. The evaluation on file did not address whether the scoop mattress limited the resident's freedom of movement, and there was inconsistency in the documentation regarding whether it was considered a restraint. A third resident was observed with bed rails in the up position, which she stated helped prevent her from falling out of bed. Staff confirmed the bed rails were used for safety, and the resident was able to get out of bed independently. However, there was a lack of documented Assistive Device/Restraint Evaluations for an extended period, indicating a failure to perform ongoing monitoring of the use of bed rails as required. The facility's policy defined restraints based on the resident's ability to remove the device and its impact on freedom of movement, but the required assessments and documentation were incomplete or missing for the residents involved.
Failure to Notify Resident Representative of Fall, UTI, and Antibiotic Initiation
Penalty
Summary
The facility failed to notify a resident's representative regarding significant changes in the resident's condition and treatment. Specifically, the representative was not informed when the resident experienced an unwitnessed fall resulting in a skin tear and bruising on the right hand, wrist, and forearm. Nursing progress notes documented the fall and resulting injuries but did not indicate that the resident's representative was notified of the incident, as required by facility policy. Additionally, the facility did not notify the representative when the resident was diagnosed with a urinary tract infection (UTI) and subsequently started on antibiotics. Although staff believed the representative was aware that a urine specimen was being collected, there was no documentation or confirmation that the representative was informed of the UTI diagnosis or the initiation of antibiotic treatment. The facility's policy requires notification of family or representatives in the event of accidents resulting in injury or significant changes in treatment, which was not followed in these instances.
Failure to Provide Accessible Grievance Process and Information
Penalty
Summary
The facility failed to develop, implement, and operationalize a comprehensive grievance policy and procedure, as required. During a walk-through, it was observed that there was no documentation on how residents could file a grievance posted in common areas, and grievance forms were only available in a single location next to the nurse's station, which was partially obstructed by a chair. There was no posting of the name or contact information for the grievance official, and no secure receptacle or written information was available for residents to file grievances anonymously. A review of facility policy indicated that such information should be provided upon admission and posted on the resident bulletin board, but these requirements were not met. Interviews revealed that a resident was unaware of the location of grievance forms or the option to file grievances anonymously, expressing a desire for a receptacle to submit anonymous grievances. A staff member confirmed the limited and inaccessible placement of grievance forms and acknowledged the absence of a secure receptacle for anonymous submissions. The facility's own policy and resident handbook outlined procedures for filing grievances, including anonymous submissions and the provision of contact information for the grievance officer, but these were not operationalized or made accessible to residents as required.
Incorrect Coding of Assistive Devices as Restraints
Penalty
Summary
The facility failed to ensure that assistive devices were accurately assessed and not incorrectly coded as restraints for two residents. In the first case, a resident who used a scoop mattress due to poor core control demonstrated the ability to turn, sit up, and get out of bed independently. Both the resident and staff confirmed that the scoop mattress did not restrict movement, and the resident's evaluation noted it was not used as a restraint. However, the Minimum Data Set (MDS) assessments inaccurately coded the scoop mattress as a restraint, despite evidence to the contrary. In the second case, another resident used bed rails as a mobility aid to prevent rolling out of bed and was able to sit and stand independently. Staff confirmed that the bed rails did not limit the resident's mobility or ability to get out of bed. Despite this, the resident's MDS assessments consistently coded the bed rails as being used daily, which was not accurate since they did not function as restraints. These inaccuracies in assessment and documentation led to the deficiency.
Failure to Assess and Document Bed Rail Use as a Restraint
Penalty
Summary
The facility failed to perform and document a complete assessment for the use of bed rails as a restraint for one resident. Observations showed the resident had bed rails in the up position on both sides of the bed and was unable to lower the rail independently due to left-sided paralysis and limited hand mobility following a stroke. The resident reported using the bed rails frequently and stated they prevented him from getting out of bed. Staff interviews confirmed that the resident was assessed and the use of bed rails was discussed, but the documentation did not reflect that the bed rails functioned as a restraint, nor did it indicate that the resident could not remove them independently. Review of the resident's records showed physician orders for bed rails for mobility, but the Assistive Device/Restraint Initial Evaluation did not identify the bed rails as a restraint or document that they limited the resident's movement. The facility's policy defined a restraint as any device the resident cannot remove easily, which restricts freedom of movement, and specified that the definition is based on the resident's functional status. The assessment failed to address these criteria, resulting in incomplete documentation and assessment for the use of bed rails as a restraint.
Failure to Ensure Timely Medication Administration and Adequate Nursing Staff Competency
Penalty
Summary
The facility failed to ensure competent nursing staff were available to provide timely medication administration and to meet residents' physical and psychosocial needs. One resident reported issues with a travel nurse, including concerns about the nurse's attitude and timeliness in completing care. Multiple residents had also complained about the care provided by travel nurses, as documented in resident council meeting minutes. Staff responsible for covering nurse call-offs stated that some travel nurses did not request assistance when running late, resulting in late medication administration. The facility primarily relied on travel nurses due to recruitment challenges, with only one full-time nurse on staff. A review of medication administration records for a resident showed that several medications, including Lisinopril, Cystex, Miralax, and acetaminophen, were administered significantly later than the scheduled times on multiple occasions. Facility policy allows a one-hour window before and after the scheduled time for medication administration, but the medications in question were given well outside this window. The facility's staffing plan and competency requirements were reviewed, but the deficiency was related to the actual practice of timely medication administration and the ability of staff, particularly travel nurses, to meet residents' needs.
Failure to Consistently Manage Pain for Hospice Resident
Penalty
Summary
The facility failed to ensure effective and consistent pain management for a hospice resident, resulting in unnecessary pain and discomfort. Observations and interviews revealed that the resident, who was under hospice care for advanced and progressive disease, received regular doses of ibuprofen and acetaminophen as ordered, but there were concerns from family members and staff regarding delays in administering stronger pain relief, such as morphine. Nursing staff often waited for up to an hour after giving acetaminophen or ibuprofen before considering morphine, even when the resident continued to experience significant pain. Documentation showed that morphine was only administered after repeated requests or when pain persisted despite initial interventions. Review of medication administration records and nursing notes indicated inconsistent documentation of pain assessments and follow-up after pain medication was given. For several months, there was no evidence of regular pain level monitoring, despite a care plan that required pain to be assessed using a 0-10 scale twice daily. When pain was documented, such as shoulder pain rated at 5/10 or 7/10, morphine was not always promptly administered, and family members had to advocate for stronger pain relief. In some instances, morphine was only given after multiple doses of acetaminophen or after direct requests from the resident or family. The facility's hospice plan of care emphasized the goal of relieving or reducing pain and required staff to assess pain characteristics and evaluate responses to medication. However, the records showed that these interventions were not consistently followed, and the resident's pain was not always managed according to the established plan. The lack of timely administration of appropriate pain medication and incomplete documentation of pain assessments contributed to the deficiency in providing adequate comfort and symptom control for the hospice resident.
Inadequate Infection Control Training for Temporary Staff
Penalty
Summary
The facility failed to ensure that temporary agency staff were trained on its infection prevention and control program standards, policies, and procedures. This deficiency was identified through observations, interviews, and record reviews. A traveling CNA, employed for approximately six months, reported that infection control training was not part of her on-board training. During an observation, this staff member did not perform proper hand hygiene. Another traveling employee, hired in mid-August 2024, also stated she did not receive infection control training upon starting. A third traveling employee, employed for about three months, confirmed that infection prevention and control was not included in her orientation. When documentation of infection control training for these staff members was requested, it was confirmed that no such documentation existed.
Failure to Adhere to Standard Precautions in Resident Care
Penalty
Summary
Staff member C failed to adhere to standard precautions related to the use of personal protective equipment and hand hygiene while providing personal care to a resident. During an observation, staff member C donned gloves without sanitizing her hands beforehand and entered the resident's room. She assisted in repositioning the resident and removed a soiled incontinence brief, cleaned the resident's peri area, and disposed of the brief without changing her gloves. Subsequently, she continued to assist with placing a Hoyer lift sling under the resident, removed the resident's clothing, and put on clean clothing, all while still wearing the dirty gloves. Staff member C then placed a clean incontinence brief into the resident's clothing cabinet and used the Hoyer lift to move the resident to a wheelchair, still without changing her gloves. After gathering the garbage, she finally removed the dirty gloves and washed her hands with soap and water. During an interview, staff member C acknowledged that she should have changed her gloves after cleaning the resident and sanitized her hands before donning and after doffing gloves. The facility's policy on standard precautions, last revised in April 2020, requires hand hygiene before and after resident contact and changing gloves to prevent cross-contamination when moving from a dirty task to a clean one.
Inaccurate MDS Coding for Diagnoses and Restraints
Penalty
Summary
The facility failed to ensure accurate coding of MDS assessments for several residents. For one resident, a diagnosis of dementia was added by the physician but was not reflected in the resident's Quarterly MDS. The diagnosis was documented in the resident's EMR only after the survey began, indicating a lack of a fail-safe mechanism to ensure new diagnoses are promptly updated. Staff interviews confirmed the oversight and the absence of a reliable process to update diagnoses after provider visits. Additionally, the facility failed to accurately document the use of bed rails and alarms in the MDS assessments for three other residents. One resident was observed with a chair alarm that was not documented in the MDS, and another resident had a bed rail that was not recorded. Conversely, a third resident's MDS inaccurately indicated the use of a bed rail that was not present. Staff interviews revealed inconsistencies and errors in MDS coding, as well as a lack of updated physician orders regarding the use of alarms and bed rails.
Failure to Update Care Plans for Medical Status and Equipment Usage
Penalty
Summary
The facility failed to revise care plans to reflect the medical status and equipment usage for two residents. For one resident, the physician's order to check blood glucose levels was discontinued on 4/12/24, but the care plan was not updated to reflect this change, leading to a lack of blood sugar monitoring. Additionally, the resident's care plan was not updated to include the use of a wheelchair, which was provided by hospice, despite observations of the resident using the wheelchair in the Day Room and dining room. For another resident, the care plan was not updated to reflect the removal of bed rails, which the resident no longer wanted. The care plan still indicated the use of bed rails, and there was no order obtained to discontinue their use. Staff interviews revealed that the care plans were not updated in a timely manner, and the facility's policy on care plan updates was not followed.
Failure to Implement Bed Rail Intervention and Update Care Plan
Penalty
Summary
The facility failed to implement the intervention of bed rails and update the care plan for a resident. During observations on two separate days, it was noted that the resident did not have bed rails on the bed, despite a physician's order dated several months prior indicating the use of a right bed side rail for bed mobility and repositioning. The resident's care plan also indicated the use of a side rail per the resident's request. Interviews with staff revealed confusion about the presence of bed rails, with one staff member noting that the bed rails were not installed after the resident moved rooms, and another stating that the resident did not want the bed rails anymore, although there was no order to discontinue their use.
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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