Missoula Health & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Missoula, Montana.
- Location
- 3018 Rattlesnake Dr, Missoula, Montana 59802
- CMS Provider Number
- 275035
- Inspections on file
- 17
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Missoula Health & Rehabilitation Center during CMS and state inspections, most recent first.
The facility did not maintain comfortable temperatures in several areas, with multiple residents reporting feeling cold and exhibiting symptoms such as shivering and blue hands. Staff acknowledged ongoing heating issues, lack of temperature documentation, and insufficient measures to address the cold, such as the absence of a blanket warmer. Additionally, a baseboard heater with detached sheet metal created a tripping hazard in a common area, and staff confirmed the risk. These deficiencies resulted in an environment that was not consistently safe or comfortable for residents.
Two residents who expressed a preference for outdoor activities were not provided opportunities to go outside, as confirmed by interviews and review of activity calendars. Staff reported not conducting any outdoor activities for several months, and facility records showed no scheduled outdoor events, despite residents' documented preferences for fresh air and outdoor time.
A resident's comprehensive Admission MDS assessment was not completed and submitted within the required 14-day period after admission, remaining open and 15 days overdue at the time of survey. Staff confirmed that such assessments are expected to be completed within the mandated timeframe.
Four residents who required assistance with activities of daily living did not receive regular showers, as evidenced by their unkempt appearance and self-reports of infrequent bathing. Staff cited short staffing as a reason for missed showers, and documentation confirmed extended periods without bathing for these residents. The facility was unable to provide a bathing policy when requested.
Two residents were not provided with group or individual activities that matched their interests or supported their well-being, resulting in minimal participation and reports of boredom. Staff interviews revealed inconsistent documentation of activity refusals and one-on-one time, and the Activities Director had not been documenting activities as required by facility policy.
Two residents with limited range of motion did not receive consistent assistance with mobility and repositioning. One resident with a recurring coccyx wound was infrequently repositioned and spent extended periods in a wheelchair without movement, despite physician orders for regular turning. Another resident, prone to sores from prolonged sitting, had sporadic documentation of restorative interventions and spent long hours in both bed and wheelchair. Staff interviews confirmed inconsistent implementation of mobility support.
A resident experienced ongoing leg pain and reported difficulty accessing staff for pain relief, while documentation frequently indicated no pain was present. Family and staff interviews revealed infrequent pain assessments, lack of repositioning, and minimal non-pharmacological interventions, resulting in inadequate pain management.
Staff failed to administer medications as ordered for two residents, including not crushing medication for a resident with a CVA and giving Carafate after meals instead of before as prescribed. Expired over-the-counter medications were also found in medication carts, and medication administration was documented before the medication was actually given.
A resident without teeth reported not being offered dental services or a referral for new dentures after her previous set did not fit, despite staff accommodating her by cutting food. Documentation and dental notes confirming a referral or dental care were not found, contrary to facility policy requiring timely referral and documentation for lost or damaged dentures.
A staff member handled a resident's food with bare hands, placing bacon on toast without gloves, in violation of facility policy prohibiting bare hand contact with food. The staff member did not immediately remove the contaminated plate, and later transferred hashbrowns from the contaminated plate to a new one before serving it to the resident. Staff interviews confirmed that such food handling practices were not permitted.
A resident who transitioned from comfort care to hospice care continued to have conflicting medication orders, with staff administering medications based on comfort care protocols instead of hospice orders. Staff interviews revealed confusion about the roles of facility and hospice staff, and documentation showed discrepancies in morphine administration instructions, indicating a lack of coordination and communication between the facility and hospice providers.
Staff did not follow infection control protocols when administering oral medications to two residents, handling tablets with bare hands and failing to use gloves as required by facility policy. This practice was observed during medication passes and confirmed as unacceptable by another staff member.
Failure to Maintain Safe and Comfortable Environment Due to Inadequate Temperature Control and Physical Hazards
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for residents by not ensuring adequate temperature control throughout the building and not repairing hazardous physical conditions. Observations revealed that the baseboard heater at the end of the North Hall near the nurses' station had detached sheet metal with sharp edges protruding, creating a tripping hazard. Staff confirmed the hazard and acknowledged the need for preventative maintenance as outlined in facility policy, which was not followed. Additionally, temperature readings in various areas of the facility were consistently low, with the North Hall at 65°F, the nurses' station at 66°F, and the South Hall at 68°F. Staff reported that the building's heating system, which relied on a boiler, was insufficient in colder weather, particularly in the North Hall, and there was no system in place to document or address temperature fluctuations. Multiple residents reported feeling cold, with some experiencing physical symptoms such as blue hands, shivering, and purple lips. Residents were observed wrapped in multiple blankets, and staff provided additional blankets as needed, but there was no blanket warmer available. Staff interviews indicated that the cold temperatures were a recurring issue each winter, and no measures were in place to improve the situation. The lack of consistent temperature monitoring and failure to address maintenance issues contributed to an environment that was neither comfortable nor safe for residents.
Failure to Honor Residents' Outdoor Activity Preferences
Penalty
Summary
The facility failed to honor the outdoor activity preferences of two residents, as evidenced by interviews and record reviews. One resident's family member reported that after admission, she was told the resident could only go outside with the smokers, who went out five times a day, but also stated that residents could go months without going outside. Another resident stated she had not been outside except for appointments and expressed a desire to go outside when the weather was comfortable, but staff had not taken her out, citing being busy. The Minimum Data Set (MDS) assessments for both residents indicated that going outside for fresh air was either 'somewhat important' or 'very important' to them. Staff interviews revealed that the activities staff member had not conducted any outside activities or used the facility's courtyard since starting in July, only feeling comfortable to do so months later. A review of the facility's activities calendars for several months showed no scheduled outside activities. The facility's policy requires the activity program to meet residents' interests and promote their well-being, but the lack of outdoor activities did not align with these stated procedures.
Failure to Complete Timely Comprehensive Admission Assessment
Penalty
Summary
The facility failed to complete a comprehensive assessment of a resident's needs, strengths, goals, life history, and preferences within the required 14 days of admission. Review of the medical record showed that the comprehensive Admission MDS assessment for one resident was still 'in progress' and had not been completed or submitted within the mandated timeframe, resulting in the assessment being 15 days late as of the last day of the survey period. During an interview, a staff member stated that Admission assessments are typically completed within 14 days of admission, but this was not the case for the resident in question.
Failure to Provide Regular Showers to Dependent Residents
Penalty
Summary
Facility staff failed to provide regular showers to four residents who were unable to perform activities of daily living independently. Observations revealed that these residents had greasy, unkempt hair and, in some cases, significant facial hair. Interviews with the residents confirmed that showers were not provided according to their expected schedule, with some residents reporting intervals of up to three weeks without a shower. Documentation review corroborated these reports, showing gaps of 12 to 22 days between showers for the affected residents. Staff interviews indicated that Certified Nursing Assistants (CNAs) were responsible for bathing tasks, but showers were sometimes missed due to short staffing or call-offs. Bathing was supposed to be documented in the electronic health record and on assignment sheets, but the records showed extended periods without showers for the residents in question. The facility was unable to provide a bathing policy when requested during the survey.
Failure to Provide Individualized Activities and Adequate Documentation
Penalty
Summary
The facility failed to provide group and individual activities that met the interests and supported the physical, mental, and psychosocial well-being of two residents. One resident reported staying in her room most of the time because the available activities, such as bingo, did not interest her, and she was observed lying in bed in the dark on multiple occasions. Her activity participation record showed involvement in only two activities over a 30-day period. Another resident expressed that she did not have much to do, did not like most scheduled activities, and was never offered in-room activities, despite her interest in coloring. She was also observed lying in bed and had participated in only one activity in the same period. Staff interviews revealed that the staff member responsible for care planning did not consistently document residents' refusals to participate in group activities or one-on-one time spent with residents. It was also noted that documentation of activities had been identified as an issue, with the Activities Director not documenting any activities until recently. The facility's activity program policy requires a multifaceted approach to meet the needs and interests of all residents, including individual and group activities, but these requirements were not met for the two residents involved.
Failure to Provide Consistent Mobility and Repositioning for Residents with Limited ROM
Penalty
Summary
The facility failed to provide appropriate assistance and positioning to maintain or improve mobility for two residents with limited range of motion. One resident reported a recurring coccyx wound and expressed a desire for more mobility work, noting that she participated in physical therapy three times a week. Observations and record reviews revealed that this resident was repositioned only once during each of two consecutive day shifts, with no consistent documentation of repositioning during night shifts as ordered by the physician. The resident was observed sitting in her wheelchair for extended periods without being moved, and both the resident and a family member expressed concerns about insufficient mobility support and infrequent repositioning. Another resident stated he developed sores on his coccyx from prolonged sitting and described a daily routine of sitting in a wheelchair for twelve hours and lying in bed for another twelve hours. Review of his records showed that restorative interventions, such as assisted transfers to a wheelchair for meals, were documented only sporadically over a 30-day period, with most days showing no activity. Staff interviews indicated that restorative duties were performed only after other CNA tasks were completed, and there was an effort to encourage more out-of-bed time, but this was not consistently implemented.
Failure to Provide Adequate Pain Management and Assessment
Penalty
Summary
A resident consistently reported significant leg pain throughout the day, stating that her legs hurt badly and that she often could not find her call light to request pain medication. She also reported that staff did not frequently ask her to rate her pain. Review of her electronic health record showed her pain was documented as 0/10 for both day and evening shifts on the day in question, despite her verbal reports of pain. The treatment administration record indicated that out of 216 opportunities from December to February, pain and an intervention were only documented 14 times, with all other days marked as not applicable. Interviews with a family member revealed ongoing concerns about the resident's pain, noting that the resident often complained of leg pain and had difficulty accessing staff for assistance. The family member also observed that staff did not reposition the resident or perform range of motion exercises, and that the resident was kept in bed for extended periods, which may have contributed to her discomfort. Staff interviews indicated no changes in pain interventions were considered necessary, and the resident continued to report pain from sitting in the same position all day.
Medication Administration and Documentation Deficiencies
Penalty
Summary
Staff failed to administer medications according to physician orders and facility policy for two residents. One resident, with a history of cerebrovascular accident (CVA), was observed receiving Tylenol 1000 mg without the medication being crushed and mixed with applesauce as specified in the medication administration record (MAR). Additionally, expired over-the-counter medications, including Vitamin B Complex, Colace, and Vitamin C, were found in medication carts on two separate halls, indicating a failure to dispose of medications past their expiration dates. Another resident was scheduled to receive Carafate 1000 mg before meals for GERD, but the medication was administered after the resident had already eaten, contrary to the physician's order and facility policy, which require administration on an empty stomach or before meals. The MAR had been preemptively checked off before the medication was actually given, and staff did not obtain a physician's order to accommodate the resident's preference for a different administration time. Facility policy requires medications to be administered as ordered and documentation to occur immediately after administration.
Failure to Provide Dental Services and Document Denture Referral
Penalty
Summary
A deficiency was identified when a resident, who was observed to be edentulous, reported that she previously had dentures that did not fit properly and that staff had not inquired about her interest in obtaining new dentures. Instead, staff accommodated her by cutting up her food, but there was no evidence that dental services were offered or arranged. The resident was alert and oriented, and staff could not provide documentation showing that dental services had been offered or that a referral had been made for denture replacement. Review of the resident's care plan indicated a problem with oral/dental health due to having no teeth, with interventions including coordinating dental care and transportation as needed. Facility policy required referral for dental services within three days of notification of lost or damaged dentures, with documentation in the medical record. However, no dental notes or documentation of referral for dental services were found for this resident during the survey period.
Failure to Use Gloves During Food Handling
Penalty
Summary
Staff failed to use gloves when handling a resident's food, as observed when a staff member picked up slices of cooked bacon with bare hands and placed them on a piece of toast on a resident's plate. The staff member acknowledged that this action was not in accordance with facility policy, which prohibits bare hand contact with food. Despite recognizing the error, the staff member did not immediately remove the contaminated plate, and the resident proceeded to eat the food. Later, the same staff member provided the resident with a new plate but transferred hashbrowns from the previously contaminated plate onto the new one. Interviews with staff confirmed that CNAs were not supposed to touch residents' food and that the facility's glove use policy specifically prohibited bare hand contact with food. The incident was directly observed and confirmed through staff interviews and policy review.
Failure to Clarify and Follow Hospice Orders for Resident
Penalty
Summary
The facility failed to ensure that hospice orders were clarified for accuracy and appropriately followed for a resident who had transitioned from comfort care to hospice care. Despite the resident being placed on hospice, staff interviews revealed confusion and inconsistency regarding the implementation of hospice versus comfort care orders. Staff members provided conflicting statements about the roles of facility staff and hospice in the care of hospice residents, with some indicating that hospice would take over care and others stating that the facility would continue to provide most care. Documentation showed that the resident continued to have active comfort care orders even after being placed on hospice, and some medications were administered according to comfort care protocols rather than hospice orders. A review of the resident's medication orders revealed discrepancies between the hospice orders and the facility's physician orders, particularly regarding the administration of morphine. The hospice order specified morphine to be given sublingually every 15 minutes as needed, while the facility's physician order indicated a different dosage and frequency. Staff interviews confirmed awareness of these discrepancies, with some staff expressing uncertainty about why the orders differed and who was responsible for clarifying them. The facility's documentation and staff responses indicated a lack of coordination and communication between the facility and hospice providers, resulting in the resident not consistently receiving care in accordance with hospice protocols.
Failure to Follow Infection Control Protocols During Medication Administration
Penalty
Summary
Staff failed to properly handle resident medications during administration for two residents. On two separate occasions, a staff member touched oral medications with bare hands before placing them in medication cups and administering them to the residents. In one instance, the medication was picked up from the medication cart after being dropped, again using bare hands. Facility policy required handwashing and glove use prior to handling tablets, but this protocol was not followed. An interview with another staff member confirmed that touching medications with bare hands was not acceptable practice due to infection control concerns and the risk of medication absorption through the skin.
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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