Montana Mental Health Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Lewistown, Montana.
- Location
- 800 Casino Creek Dr, Lewistown, Montana 59457
- CMS Provider Number
- 27A052
- Inspections on file
- 27
- Latest survey
- November 19, 2025
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Montana Mental Health Nursing Home during CMS and state inspections, most recent first.
Leadership failed to identify and address a nurse's ongoing cognitive and performance issues, resulting in over 50 medication errors and missed care tasks for multiple residents. Despite repeated reports from staff about the nurse's confusion, slurred speech, and unresponsiveness, supervisors did not document or investigate these concerns, allowing neglect of care to continue for several months.
The facility did not have an effective system to identify or correct undocumented medication administrations, resulting in numerous missed doses and undocumented medication checks for multiple residents. Staff failed to document reasons for missed medications as required by policy, and pharmacy oversight did not address these ongoing issues, leaving medication errors unaddressed in the medical records.
Administrative staff did not act on repeated reports of an LPN exhibiting confusion, slurred speech, and other cognitive changes, nor did they investigate or document over 50 medication errors involving multiple residents. Ongoing issues with missed medication doses, patch checks, and removals were not identified or corrected, and facility policies for medication administration and error reporting were not consistently followed.
A staff member failed to provide necessary ADL care to a dependent resident who required full assistance, resulting in the resident being left in a soiled state with dried feces on their body, clothing, and wheelchair. The staff member did not follow instructions to change the resident and left the shift without completing the task, which was identified as neglect of care.
A resident did not receive enough food and fluids to maintain their health, as surveyors found that the facility did not meet the individual's nutritional and hydration needs.
A resident experienced a severe weight loss of 27 pounds over three months, but the physician, dietitian, and representative were not promptly notified. Documentation showed delays in communication, with the physician informed only during a routine visit and the dietitian and guardian notified days later. Staff interviews confirmed the delay in recognizing and reporting the weight loss.
The facility failed to report resident-to-resident abuse allegations to the State Survey Agency within 24 hours for six residents. Incidents were reported late despite procedures requiring timely reporting through the BOUNDS system. Interviews revealed that floor staff report incidents to nurses, who then alert an abuse team via a confidential app, but delays still occurred.
The facility failed to timely complete POLST forms for two residents and did not ensure an advanced directive was in place for another. Interviews revealed that only physicians could complete POLST forms, often delaying their completion. One resident's POLST was not completed for over thirty days, and another's took almost two months. Additionally, there was no documentation of an advanced directive discussion for a third resident.
The facility failed to dispose of expired Shingrix vaccines and did not consistently monitor medication refrigerator and freezer temperatures. Temperature logs were incomplete, and expired vaccines were found in the treatment room refrigerator. Staff interviews revealed inconsistencies in monitoring practices, with missing documentation for several dates, contrary to facility policy.
The facility failed to maintain proper food safety practices in the Firefly and Glacier unit kitchens, with missing documentation of refrigerator and freezer temperatures and unlabeled food found in the freezer. Night shift nurses were responsible for logging temperatures, but logs showed numerous missing entries, indicating a systemic issue with monitoring food storage conditions.
The facility failed to ensure complete and properly labeled medical records for several residents. POLST forms were incomplete, lacking signatures, dates, and phone numbers. An interdisciplinary progress note for a resident lacked identifying information, and another resident's medication administration records were not clearly labeled with the month or year. Staff interviews revealed that only physicians were allowed to complete POLST forms, leading to delays.
A facility failed to notify a resident's guardian of a transfer to the emergency department, as required by policy. The resident was admitted to the emergency department, but there was no documentation of guardian notification. Staff confirmed the guardian should have been informed, highlighting a lapse in communication and policy adherence.
A resident left a facility against medical advice due to a lack of effective discharge planning. The resident's court commitment expired without re-commitment, allowing voluntary status. Despite expressing a desire to leave, the facility did not prepare for discharge, assuming the resident was content. Upon leaving, the resident received a three-day medication supply without proper orders, and no follow-up care or accommodations were arranged.
A resident was not administered oxygen at the prescribed rate, and the facility failed to maintain respiratory equipment properly. The oxygen cannula was found on the floor, and the concentrator's filters were dirty. The facility's policy required monthly cleaning of the filters, but documentation showed this was not completed. Additionally, there was no record of oxygen monitoring or liter flow documentation for two months.
Failure to Address Staff Member's Declining Performance Led to Neglect of Resident Care
Penalty
Summary
Leadership staff failed to ensure residents were free from neglect by not identifying, addressing, or correcting concerns related to a staff member's performance over several months. Staff member R was responsible for more than 50 medication errors affecting 11 residents, including failures to administer medications, complete glucose checks, and perform skin checks as required by physician orders. Despite these errors, the facility reported that no harm was found for the residents, but the required care was not provided as ordered. Multiple staff members observed and reported significant changes in staff member R's behavior and cognitive status, such as confusion, slurred speech, slowed gait, weight loss, and periods of unresponsiveness. These concerns were communicated to supervisory staff, but were not documented, investigated, or escalated appropriately. Staff member D, after receiving reports, only briefly observed staff member R and did not take further action unless she personally identified an issue. Other staff, including staff members E and L, also noted missed medications and cognitive changes but did not report or document these concerns to higher management. The lack of an effective system to track, investigate, and respond to repeated reports of staff member R's declining performance and health resulted in ongoing neglect of care for multiple residents. The facility leadership did not ensure that concerns about staff member R's ability to safely perform her duties were properly managed, leading to a prolonged period during which residents did not consistently receive necessary medications, treatments, or monitoring as ordered.
Failure to Identify and Document Medication Administration Omissions
Penalty
Summary
The facility failed to maintain an effective and accurate system for identifying and correcting medication administration documentation omissions for physician-ordered medications. Multiple residents had numerous undocumented medication administrations, with no explanations or reasons recorded in the medication administration records (MARs) or nursing notes. The omissions included a wide range of medications, such as antipsychotics, insulin, pain medications, and supplements, and in some cases, checks for controlled substances like fentanyl patches were not documented. Facility policy required that such omissions be identified and addressed as medication errors, but this was not done. A review of the records for 14 out of 17 sampled residents revealed repeated instances of missed medication administrations and undocumented medication checks. For example, one resident had ten missed doses of various medications, another had 25 missed administrations, and another had 59 undocumented fentanyl patch checks. In all cases, there was no documentation to explain why the medications were not administered, and the medical records did not address the errors or any potential outcomes. Staff interviews confirmed that the process for identifying and documenting these omissions was not followed, and staff responsible for pharmacy services did not consider undocumented administrations as medication errors unless specifically reported or related to narcotics discrepancies. The contracted pharmacy also failed to identify or address these ongoing concerns. Staff interviews indicated a lack of clarity regarding who was responsible for reviewing MARs for missed doses or documentation holes. Facility policies clearly defined medication omissions as errors and required immediate documentation and follow-up, but these procedures were not implemented, resulting in unaddressed medication errors for a significant number of residents.
Failure to Address Staff Performance and Medication Administration Deficiencies
Penalty
Summary
Facility administrative staff failed to act in a timely and thorough manner to address concerns regarding a staff member responsible for resident care and services. Multiple staff members reported ongoing issues with this staff member, including confusion, slurred speech, calling people by the wrong name, weight loss, and wandering, over a period of three to four months. Despite these reports, administrative staff did not investigate, document, or escalate the concerns, nor did they ensure that the staff member was following facility policies. The staff member in question was involved in more than 50 medication errors, including failure to administer medications, improper glucose checks, and incomplete skin checks, affecting 11 residents. Concerns about the staff member's cognitive status and performance were not adequately addressed or documented by supervisors. Additionally, administrative staff did not identify or act on ongoing issues related to the facility's medication administration policy, procedures, or system. Medication administration records for 12 residents showed 138 missed medications, 59 missed fentanyl patch checks, and 17 missed lidocaine removals over a two-and-a-half-month period. Staff interviews revealed uncertainty about who was responsible for reviewing medication records for missed doses, and missed doses were only considered when medications were returned to the pharmacy without explanation. The facility's policies required immediate documentation of medication administration and errors, but these were not consistently followed. The deficiencies affected a significant number of residents, with ongoing medication errors and lack of proper oversight by administrative staff. The failure to investigate, document, and address staff performance and medication administration concerns resulted in continued issues with resident care and services. The administrative staff's inaction and lack of adherence to facility policies contributed to the persistence of these problems.
Failure to Provide Required ADL Care Resulting in Resident Neglect
Penalty
Summary
A staff member failed to provide necessary activities of daily living (ADL) care to a dependent resident who required full assistance for ambulation and brief changes. Despite being instructed by a nurse to change the resident's soiled brief, the staff member did not perform the task and left the shift. The resident was later found with dried feces up his back, on his clothing, in his wheelchair, and under the wheelchair cushion. Witness statements confirmed that the staff member did not spend sufficient time to properly change the resident and that the odor of soiling was noticeable to other staff in the area. The incident was reported as neglect of care, and it was determined to be an isolated event involving this particular resident and staff member, rather than a systemic issue. The staff member in question had a history of performance issues and was on administrative leave at the time of the investigation. Facility policies reviewed defined neglect as the failure to provide necessary goods and services to avoid physical harm, pain, mental anguish, or emotional distress, and included toileting as a required ADL service.
Failure to Provide Adequate Food and Fluids
Penalty
Summary
The facility failed to provide sufficient food and fluids to maintain a resident's health. This deficiency was identified by surveyors based on observations and records indicating that the nutritional and hydration needs of at least one resident were not adequately met. The lack of appropriate provision of food and fluids resulted in a failure to support the resident's overall health status.
Failure to Timely Notify Physician, Dietitian, and Representative of Severe Weight Loss
Penalty
Summary
The facility failed to notify a resident's physician, dietitian, and representative in a timely manner after the resident experienced a severe weight loss. The resident lost 27 pounds, representing an 11.86% decrease in body weight over a three-month period, with a 20-pound loss occurring in less than two months. Documentation in the medical record did not show immediate notification to the physician, dietitian, or the resident's representative regarding this significant change. Nursing progress notes indicated that the medical physician was only notified of the weight loss during a routine 90-day visit, and the dietitian was consulted several days later. The resident's guardian was informed after the fact, and attempts to reach the family were not immediately successful. Staff interviews confirmed that awareness of the weight loss occurred only in the days leading up to the notification, and there was a delay in obtaining a reweigh when a significant weight difference was first noted.
Failure to Timely Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report allegations of resident-to-resident abuse to the State Survey Agency within the required 24-hour timeframe for six residents. Specific incidents included an allegation involving two residents that occurred on July 6, 2024, but was not reported until July 8, 2024. Another incident involving two different residents occurred on July 22, 2024, and was reported on July 24, 2024. Additionally, an incident on September 12, 2024, involving two more residents was not reported until September 16, 2024. These delays in reporting were identified during interviews and record reviews conducted by surveyors. Interviews with facility staff revealed that floor staff are responsible for reporting incidents to the nurse on duty, who then fills out a report. The facility has an abuse team that oversees investigations, and the nurse on duty is expected to alert the team via a confidential texting application. The team designates an individual to investigate and submit the report through the facility's online reporting system, BOUNDS. Despite these procedures, the facility's document titled "Abuse, Misappropriations, and/or Neglect of Residents" mandates that the administrator and quality coordinator input the alleged abuse report into the BOUNDS system within 24 hours, which was not adhered to in these cases.
Failure to Timely Complete POLST and Advanced Directives
Penalty
Summary
The facility failed to address the timely completion or implementation of treatment wishes for residents, specifically related to the Provider Orders for Life-Sustaining Treatment (POLST) forms. Resident #43's POLST was not completed for over thirty days after admission, despite the resident recalling being asked about her code status. Similarly, resident #60's POLST form was not completed until almost two months after admission, which did not align with the facility's policy. Interviews with staff members revealed that physicians were the only ones allowed to complete POLST forms, and it was common for physicians to not see residents for two to three weeks after admission, resulting in residents being considered full code unless treatment wishes were documented. Additionally, the facility failed to ensure advanced directives were in place for resident #37. The medical record for resident #37 showed no advanced directive was filled out, and there was no documentation of a discussion regarding her wishes. The facility did not provide information about an advanced directive or a refusal for resident #37 before the end of the survey. Staff interviews indicated that the resident's provider would discuss advanced directives during the initial visit, which was expected within the first thirty days after admission. The facility conducted monthly audits to ensure POLST forms were present and properly filled out, but these deficiencies indicate a lapse in the timely completion and documentation of residents' treatment wishes.
Expired Immunizations and Inadequate Temperature Monitoring
Penalty
Summary
The facility failed to ensure proper disposal of expired immunizations and did not adequately monitor the temperatures of medication refrigerators and freezers. During a record review, it was found that temperature logs for the treatment room immunization freezer and refrigerator were incomplete for several dates. An observation revealed expired Shingrix vaccines in the treatment room refrigerator, which were not disposed of as per protocol. Staff member L mentioned that expired immunizations are typically returned to the pharmacy by staff member K, who frequently visits the treatment room. However, the expired vaccines were still present, indicating a lapse in the process. Interviews with staff members L and K revealed inconsistencies in the monitoring of refrigerator temperatures. Staff member K stated that she checks the treatment room fridge daily when present, while night shift nurses are responsible for checking temperatures on weekends or holidays. However, documentation showed missing temperature logs for several dates. The facility's policy requires daily temperature checks and logging by designated personnel, but this was not consistently followed, leading to potential risks associated with improper storage conditions for medications and immunizations.
Failure to Maintain Proper Food Safety Practices
Penalty
Summary
The facility failed to ensure proper food safety practices in the Firefly and Glacier unit kitchens, as observed during a survey. Specifically, there was a lack of consistent documentation of refrigerator and freezer temperatures, with missing entries on multiple dates across several months. This failure to record temperatures was noted in logs for both units, indicating a systemic issue with monitoring food storage conditions. Additionally, during observations, a Styrofoam bowl with food was found in the Firefly unit freezer, unlabeled and undated, which is against the facility's policy for food storage. Interviews with staff members revealed that the responsibility for checking and logging refrigerator and freezer temperatures fell to the night shift nurses. However, the logs showed numerous instances of missing documentation, suggesting that this task was not consistently performed. The facility's policy requires that temperatures be checked and logged daily by designated personnel, and that all refrigerated food be labeled, dated, and monitored. The lack of adherence to these protocols could potentially lead to foodborne illnesses and improper infection control practices for residents consuming food from these units.
Incomplete and Unlabeled Medical Records
Penalty
Summary
The facility failed to ensure that resident medical record documentation was complete and properly labeled for four of the sampled residents. Specifically, the POLST forms for residents were found to be incomplete, lacking necessary information such as the preparer's signature, date, and phone numbers. For instance, resident #11's POLST form was missing the preparer's information and date, while resident #43's form lacked the signature and phone numbers. Additionally, resident #60's form did not include the medical provider's phone number. Interviews with staff members revealed that only physicians were allowed to complete the POLST forms, and there was a delay in completion until the physician or nurse practitioner made their initial visit. Furthermore, resident #66's interdisciplinary progress note lacked identifying information, making it unclear which resident the note pertained to. Additionally, resident #43's medication administration records were provided in two sets, both lacking clear labeling of the month or year, making it difficult to determine the dates of the records. Staff member B was unable to identify the month for the medication administration records, indicating a lack of proper documentation and organization within the facility's record-keeping practices.
Failure to Notify Guardian of Emergency Department Transfer
Penalty
Summary
The facility failed to notify the guardian of a resident's transfer to the emergency department, which constitutes a deficiency in communication and adherence to policy. The resident was admitted to the emergency department at 9:49 p.m. on 10/20/24, but there was no documentation in the medical record indicating that the guardian was informed of this transfer. Interviews conducted on 10/23/24 revealed that the guardian was not notified, and staff acknowledged that the guardian should have been informed according to the facility's policy. The policy, revised on 2/6/2023, mandates that family or guardians be contacted in coordination with nursing services when significant events occur, such as a change in the resident's condition.
Failure in Discharge Planning for Resident Leaving Against Medical Advice
Penalty
Summary
The facility failed to implement an effective discharge planning process for a resident who left the facility against medical advice. The resident was initially required to stay at the facility due to a court commitment for a minimum of 90 days. However, the court commitment expired, and a re-commitment was not filed in time, allowing the resident to be in the facility on a voluntary basis. Despite multiple indications from the resident expressing a desire to leave, including exit-seeking behavior and a preference to be in a place where smoking was allowed, the facility did not initiate discharge planning. Staff members assumed the resident was content at the facility and did not take steps to prepare for a potential discharge. When the resident eventually left against medical advice, the facility did not have a proper discharge plan in place. The resident was given a three-day supply of medications, but there were no physician orders for this in the medical record. Additionally, there were no arrangements made for a follow-up appointment, ensuring the resident had a wheelchair, or ensuring the resident had enough medication until a new prescription could be obtained. The lack of discharge planning was attributed to assumptions made by staff about the resident's satisfaction with the facility and unresolved financial issues related to the resident's co-ownership of a house.
Oxygen Administration and Equipment Maintenance Deficiency
Penalty
Summary
The facility failed to administer oxygen to a resident at the rate prescribed by the physician and did not maintain respiratory equipment according to acceptable standards. During an observation, a resident was found using oxygen via a nasal cannula connected to an oxygen concentrator, with the cannula lying on the floor and the nose pieces in direct contact with the floor. The oxygen concentrator was set at two and one-half liters per minute, despite the physician's order allowing up to five liters per minute. The resident was unaware of the need to clean the filter on the concentrator, which was found to have a fine layer of gray particles and a heavy layer of particles and hair-like substances. The facility's policy required the air inlet filter on the concentrator to be washed and rinsed in warm soapy water at least monthly and as needed. However, the certified nurse assistant documentation flow sheets showed that the oxygen filter cleaning scheduled for a specific date had not been completed. Additionally, the resident's monthly medication administration records and treatment records lacked documentation of oxygen monitoring results or the oxygen liter flow for two months. Staff interviews revealed that the night shift was responsible for cleaning the filters monthly, and the company renting the concentrators performed quarterly maintenance.
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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