Mount Ascension Transitional Care Of Cascadia
Inspection history, citations, penalties and survey trends for this long-term care facility in Helena, Montana.
- Location
- 2475 Winne Ave, Helena, Montana 59601
- CMS Provider Number
- 275044
- Inspections on file
- 27
- Latest survey
- March 24, 2026
- Citations (last 12 mo.)
- 31
Citation history
Health deficiencies cited at Mount Ascension Transitional Care Of Cascadia during CMS and state inspections, most recent first.
A resident with dementia, cognitive decline, osteopenia, and a recent iliac fracture experienced three falls, including unwitnessed falls that resulted in bruising, a facial laceration, hematoma, skin tear, decreased LOC, and hospital transfer. Staff reported that IDT post-fall assessments were normally done within 24 hours to identify root causes and interventions, but acknowledged that this resident’s IDT reviews were not timely. The IDT post-fall note for the first fall, completed much later, identified issues with walker use and short-term memory and listed interventions such as increased visual checks, cueing, walker evaluation, and focused OT/PT, yet these interventions were not documented in the EHR or added to the care plan before the subsequent falls, contrary to the facility’s fall management policy.
The facility failed to implement an effective, data‑driven QAPI program when QAPI meetings were used mainly for informational departmental updates rather than systematic problem‑solving, root cause analysis, and follow‑up on identified concerns. Staff reported that PIPs existed in multiple departments, but meeting records showed that issues such as infection control, housekeeping/environmental problems, care plans, pain management, and skin/wound care were repeatedly identified without documented root cause analysis, measurable goals, timelines, or monitoring of interventions. Review of PIP and QAPI documentation showed a lack of defined action plans and evaluation of effectiveness, despite a written QAPI policy requiring regular analysis of quality deficiencies and structured performance improvement activities.
Two residents were found living in rooms that were not clean or well maintained, including dirty windows and windowsills, trash and debris on floors, damaged and unpainted walls, dust accumulation, an overflowing trash can, and discarded PPE on the floor. One resident reported that window and privacy curtains had not been washed in two years and that staff refused to remove them for cleaning, while another reported that no one had cleaned their room for at least two days. Staff interviews revealed inconsistent and conflicting descriptions of daily and deep cleaning practices, limited housekeeping coverage with one housekeeper per floor, uncertainty about whether curtains were removable, and a deep cleaning log whose reliability was questioned. Although facility documents referenced monthly complete room cleaning and a planned privacy curtain cleaning rotation, no documentation was produced to show that these practices were actually implemented.
Surveyors found that a resident on Enhanced Droplet Precautions for COVID-19 did not receive care consistent with posted PPE and hand hygiene requirements. Staff repeatedly entered and exited the resident’s room wearing only a face mask, without gowns, gloves, or eye protection, and did not perform hand hygiene between resident contacts. The PPE cart lacked gowns, no used gowns were found in the room trash, and the resident reported that staff did not always wear full isolation gear. Staff interviews revealed outdated or incomplete training on transmission-based precautions, misunderstanding of eye protection and Enhanced Barrier Precautions, and the facility could not provide documentation of current staff education despite having policies and CDC guidance requiring full PPE for COVID-19.
A resident with neuromuscular weakness, dysphagia, and speech impairments was found with seven capsules left in a medicine cup at the bedside, accessible without supervision. A staff member reported she had left the medications in the room while the resident was in the shower and acknowledged there was likely no MD order for self-administration. Record review confirmed there was no self-administration safety assessment, no physician order authorizing self-administration, and no swallow evaluation documenting the resident's ability to safely self-administer medications, while the failure was noted to place the resident at risk for choking, aspiration, and medication errors.
A resident was admitted with a physician’s order for PT to evaluate and treat, and the admission orders were signed off by nursing staff, but the order was never processed to the therapy department and no PT evaluation or treatment occurred during the stay. Staff interviews revealed that the usual process requires the admitting nurse to forward therapy orders to the therapy department so a PT can complete an initial assessment and PTAs can provide treatments, but in this case the order was either missed or not forwarded, leaving therapy staff unaware of it. Facility records, including the MDS and census reports, confirmed that the resident was never enrolled in therapy services despite the active order.
Dietary staff failed to follow sanitary food-handling and infection control practices during meal preparation and service. During a COVID-19 outbreak, two dietary staff worked in the food preparation area without infection control face masks. At breakfast, one staff member used the same gloved hands to handle trays, tray cards, food racks, and open juice glasses without changing gloves or performing hand hygiene, while another staff member handled sausages, muffins, eggs, cereal bowls, and plate surfaces with bare hands and no gloves or handwashing. At lunch, staff used bare hands to cut and plate pizza, scrape and arrange beans, place buns, and cut and plate sandwiches. A staff member reported that kitchen staff should never touch food with bare hands, confirming that these observed practices did not follow expected infection control standards.
A resident was transferred to a hospital and did not return, yet the facility failed to provide or document the required written transfer and bed-hold notices. Staff reported that residents transferring out are supposed to sign transfer and bed-hold forms, with nurses completing and assisting with signatures as needed, but could not confirm that this occurred for the resident involved. Review of facility policies showed that written notices explaining the reason, effective date, and destination of a transfer, as well as bed-hold notices given in advance and at the time of transfer or within 24 hours for emergencies, must be provided and kept in the clinical record; however, no such notices were found for this resident, and a facility document indicated there was no bed hold for the transfer.
A resident who was dependent on staff for bathing and preferred showers twice weekly did not consistently receive scheduled showers, with records showing multiple missed shower days and extended intervals between showers over a three‑month period. CNAs reported using a shower schedule and a list at the nurse’s station, re‑approaching residents after refusals, and documenting refusals on shower refusal forms, yet only one refusal form was found in the notebook. The facility’s ADL policy required assistance with hygiene based on individual needs and preferences and documentation of ADL assistance and resident response, but the resident’s documented shower frequency did not match the stated preference and care plan.
A resident receiving chemotherapy for metastatic cancer tested positive for COVID-19 and was prescribed Molnupiravir, an oral antiviral authorized for high-risk adults with mild-to-moderate COVID-19. Nursing notes show the drug was expected from the pharmacy the next morning but had still not arrived by later that day, and it was not administered until that night when it finally came from an out-of-state pharmacy, resulting in a two-day delay in treatment. A staff member reported that medications were sometimes not delivered timely, that they relied on an out-of-state pharmacy to restock despite having an Omnicell and access to a local satellite pharmacy, and that this case exemplified failure to obtain COVID-19 treatment medication promptly, contrary to the facility’s pharmacy services policy requiring timely provision of routine and emergency medications 24/7.
A resident with an ostomy and recent surgical site became anxious and repeatedly dug at the stoma and wound, causing bleeding. After administering PRN lorazepam and morphine without resolving the behavior, an agency nurse, who had not received facility-specific abuse and restraint training, attempted to wrap the resident’s hands with washcloths and pillowcases to stop her from digging. Another staff member intervened, stopped the wrapping, and removed the materials, but during the episode the resident bit at the wrapped hand and cracked a tooth. Review of personnel files showed that required abuse and restraint training had not been completed before these agency staff began providing care, leading to a deficiency for improper use of physical restraints.
A resident with schizophrenia, depression, and moderate cognitive impairment, identified as an elopement risk, was taken to a dental appointment with clear written instructions that staff must stay with him. The transporting staff member, though aware of the elopement risk, left the resident unattended once he was taken to the exam room, and the resident subsequently left the office alone, took a taxi, and went to a relative’s home about two miles away, with his whereabouts unknown for about an hour. After the event, facility staff completed only a basic incident report and did not conduct or document an IDT review, after-action/post-elopement evaluation, root cause analysis, or corrective actions, despite an existing elopement policy requiring such investigation and documentation.
A resident with mental health issues, impaired decision-making, and a documented elopement risk repeatedly expressed a desire to leave, including plans to travel out of state, yet the facility did not individualize the care plan to include family-discussed interventions such as supervised walks, supervised medical appointments, or measures tied to medication refusal and increased elopement risk. Behavior monitoring for wandering and exit-seeking was not implemented despite documented nighttime pacing and an attempted self-discharge. During transport to a dental appointment, a staff member who knew the resident was an elopement risk left the resident unsupervised at the clinic, contrary to expectations noted on the appointment schedule, allowing the resident to leave by taxi to a relative’s home. The facility did not complete a documented IDT after-action investigation, did not promptly perform a post-elopement evaluation, and only maintained largely generic elopement care plan interventions after the resident’s return.
The facility did not follow its grievance policy, resulting in multiple unresolved complaints from residents and their representatives. Grievances about care issues, such as delayed call light response, improper repositioning for pressure ulcer prevention, and staff-inflicted injuries, were not investigated or documented. Staff interviews confirmed that grievances were often ignored or deprioritized, and required follow-up steps were not completed, leaving residents without resolution or communication regarding their concerns.
The facility did not report multiple allegations of abuse and neglect to the State Survey Agency as required. A resident complained of not being repositioned and missed care, while two others reported being hurt by staff during care and transfers. These incidents were documented but not reported or investigated according to policy.
The facility did not investigate or report multiple complaints of potential abuse and neglect, including two residents who reported being hurt by staff during care and a resident with pressure ulcers who was not repositioned as required. Staff confirmed that these incidents were not reported or investigated according to facility policy.
The facility failed to maintain RN coverage for at least eight consecutive hours daily, as required. Interviews and record reviews showed that on several occasions, no RN was scheduled, leading to concerns from residents about staffing levels. Staff attempted to find replacements using a program or management staff. Concerns were also raised about the accuracy of PBJ reporting.
The facility failed to implement enhanced barrier precautions (EBP) in the 100 north hall, as staff did not use appropriate PPE when caring for residents with catheters, tubes, or wounds. Observations showed a lack of EBP signage and staff awareness, leading to inadequate infection control practices.
The facility's antibiotic stewardship program was found deficient due to inadequate infection surveillance and monitoring of antibiotic use. A staff member reported a lack of support and adherence to McGreer's criteria by healthcare providers. The infection control log showed several urinary tract infections treated with antibiotics without proper culture and sensitivity testing, and the facility struggled to track organisms for residents on antibiotics from hospitals.
The facility failed to ensure proper screening and documentation for influenza, pneumonia, and COVID-19 immunizations for residents. Three residents were not screened for pneumococcal vaccines, and there was no documentation of either vaccine administration or signed declinations. One resident had not received an updated pneumococcal vaccine since 2000, while two others had no records of receiving or declining the vaccine. A staff member was unaware of her responsibility for immunizations and only ordered the vaccines after the surveyor's request.
A resident requested to be sent to the hospital due to feeling unwell and low oxygen levels, but the facility staff did not arrange the transfer. Instead, a non-facility caregiver called an ambulance, leading to the resident's transport to the hospital. This incident highlights a failure to respect the resident's rights to self-determination and participation in their treatment.
A resident's allegation of neglect was not reported to the State Survey Agency within the required 24-hour period. The incident involved the resident feeling unwell and requesting hospital transfer, which was delayed by staff. Despite internal reminders, the report was submitted late after an anonymous complaint was received.
A resident's request to go to the hospital due to feeling unwell was not promptly addressed by facility staff, despite critically low oxygen saturation levels. The resident's non-facility caregiver eventually called an ambulance, leading to the resident's transfer to a hospital. The facility failed to document follow-up assessments or actions taken, violating their documentation policy.
The facility failed to ensure physician orders for oxygen therapy were present in the EHR for two residents and did not consistently label oxygen supplies with cleaning or change dates for five residents. Observations revealed that residents' oxygen equipment was not labeled, and staff were uncertain about the necessity of physician orders for oxygen therapy.
A facility failed to implement a resident's dietary preferences and address therapeutic diet changes over the weekend. The resident, who had difficulty swallowing dry meats, did not receive meals with gravy as preferred, and diet changes were not communicated timely, leading to inappropriate meal preparation. Staff acknowledged discrepancies in following the diet order, highlighting a lack of consistent processes for weekend diet changes.
The facility failed to maintain water temperatures within CDC guidelines to prevent Legionella growth, conducting bi-weekly instead of weekly checks. Residents reported not seeing temperature checks, and observations noted dirty sinks and toilets. Staff lacked specific education on Legionella prevention, with no documentation provided. The infection preventionist did not intervene when a resident was diagnosed with Legionella, and preventative measures were not increased.
A resident in an LTC facility suffered a fractured hip due to inadequate assistance during a transfer, requiring surgery. The facility also failed to maintain a smoke-free environment, with one resident using a marijuana vape pen in bed and two others smoking on the premises, despite policies prohibiting such activities. Staff were aware of these issues but did not enforce the facility's policies, creating safety hazards.
The facility failed to conduct and document required care conferences, excluding residents and their representatives from participating in care planning. Interviews revealed that residents and their representatives were not invited to attend, and EHR reviews showed missing documentation for several MDS periods. Staff acknowledged the backlog and planned to address it, but the facility did not provide a policy for care conferences.
The facility failed to inform residents about the grievance process and how to file grievances, as multiple residents were unaware of grievance forms or the process. Staff interviews revealed inadequate handling and documentation of grievances, with some staff instructed not to file grievances or provide the ombudsman's contact information. The facility's grievance logs showed minimal entries, despite numerous complaints raised in resident council meetings, and staff were unable to locate documentation for these grievances.
The facility failed to report abuse allegations and investigation results to the State Survey Agency and Adult Protective Services. A resident reported verbal and physical abuse by a CNA, but the staff dismissed the claims without investigation. Another resident's fall resulting in rib fractures was not reported within the required timeframe. These actions violate the facility's policy on reporting abuse and serious injuries.
A facility failed to investigate and report alleged abuse by a CNA towards a resident, who claimed verbal abuse and threats from another resident. The facility did not offer counseling or document the allegations, and staff dismissed the incident as 'old news'. The facility's policy on reporting such incidents was not followed.
Two residents in the facility developed and experienced worsening pressure ulcers due to inadequate care. One resident's sacral ulcer progressed from Stage III to Stage IV, with multiple missed dressing changes and pain reported. Another resident developed a Stage III ulcer from a skin tear caused by improper use of a Hoyer lift sling. The facility failed to implement effective pressure ulcer prevention strategies and did not follow physician orders for wound care.
A resident at high risk for pressure ulcers developed a Stage IV ulcer due to the facility's failure to follow wound care protocols. Despite staff awareness of necessary interventions, multiple dressing changes were missed, and the resident arrived at the wound clinic without dressings on two occasions.
The facility failed to develop comprehensive care plans for two residents, leading to deficiencies in care. One resident developed a Stage III pressure ulcer due to improper handling with a mechanical lift, and the care plan lacked interventions for ulcer prevention and treatment. Another resident experienced pain during wound dressing changes, but the care plan did not include specific pain management interventions, despite the availability of pain medication.
A facility failed to provide adequate pain management for a resident with a Stage IV ulcer during dressing changes. Despite orders for pre-appointment pain medication, records were unclear if medication was given before dressing changes. Staff interviews indicated pain should be reported and managed, but the care plan lacked specific interventions for pain related to the wound.
Failure to Complete Timely IDT Post-Fall Assessment and Implement Fall-Prevention Interventions
Penalty
Summary
Surveyors identified a failure by the facility to ensure timely, comprehensive IDT post-fall assessments, root cause analyses, and implementation and documentation of fall-prevention interventions for a resident with multiple falls. The resident was admitted after a hospitalization for a right iliac crest fracture and had diagnoses including osteopenia, degenerative changes, altered mental status, dementia, cognitive decline, weight loss, and lethargy, with documentation that her cognitive decline had progressed rapidly over the prior month. Nursing notes showed the resident experienced three falls: the first occurred when she attempted to park her wheeled walker without locking the brakes and fell on her right knee and hip; the second was an unwitnessed fall resulting in bruising to the right elbow and hip; and the third was an unwitnessed fall resulting in a facial laceration, hematoma to the left brow, a skin tear to the left elbow, decreased level of consciousness, and transfer to the hospital. During this period, the resident was also placed on palliative care and tested positive for COVID-19. Interviews with staff revealed that IDT post-fall assessments were typically completed within 24 hours and used to identify root causes and interventions, with care plans updated as needed, but staff acknowledged that IDT meetings for this resident did not occur in a timely manner. The IDT post-fall note for the first fall, which was not dated until nearly two weeks later, identified root causes related to improper walker use and short-term memory deficits, and listed interventions such as more frequent visual checks, consistent cueing for safe walker handling, evaluation of the walker, and continued OT/PT with a focus on fall prevention. However, review of the electronic health record and the resident’s care plan showed no evidence that these interventions were implemented or added to the care plan before the resident’s subsequent falls and hospitalization. This was inconsistent with the facility’s own Fall Response & Management policy, which required evaluation of causal factors after a fall, review and updating of the care plan with individualized measures, and IDT review and placement of interventions following fall incidents.
Failure to Implement Effective, Data‑Driven QAPI Program
Penalty
Summary
The facility failed to develop and implement an effective, comprehensive, data‑driven QAPI program. Interviews revealed that department managers used a shared PowerPoint to present departmental updates and Performance Improvement Projects (PIPs) at quarterly QAPI meetings, and that each department had multiple PIPs in the past year. However, one staff member reported that QAPI meetings were primarily informational, focused on reviewing departmental activities rather than problem‑solving or process improvement, and did not consistently include follow‑up on previously identified concerns. Another staff member stated that the QAPI committee "definitely needs to be more than it has been" and that meetings should occur more frequently to address ongoing system failures and monitor progress of PIPs. Review of quarterly QAPI meeting documentation for 2025 showed that multiple quality concerns were identified, including infection control practices, housekeeping/environmental issues, care plans, pain management, and skin and wound issues, but the records lacked evidence of root cause analysis, clearly defined action plans, or monitoring for effectiveness and sustained improvement. Review of PIP documentation for 2025 showed that multiple projects were initiated without measurable goals, timelines for completion, or evidence of ongoing evaluation of interventions, and several issues were repeatedly identified across multiple meetings without documented resolution or progress. These practices did not align with the facility’s written QAPI policy, which required at least monthly meetings to identify performance improvement opportunities, establish goals and performance indicators, systematically analyze underlying causes, prioritize and develop action plans, implement process improvement strategies, and evaluate effectiveness and sustained results.
Failure to Maintain Clean, Sanitary, and Homelike Resident Rooms
Penalty
Summary
The deficiency involves the facility’s failure to provide a clean, sanitary, and homelike environment for residents, as evidenced by conditions in two sampled residents’ rooms and inconsistent housekeeping practices. In one resident’s room, surveyors observed soiled window surfaces, visibly dirty windowsills, trash items (a paper wrapper and medicine cup) on the floor near the trash can, and wall surfaces with holes, cracks, and missing paint. The resident reported living in the facility for two years and stated that neither the window curtains nor the privacy curtains had been washed during that time. The resident further stated that when they asked housekeepers about cleaning the curtains, they were told the curtains could not be taken down due to privacy concerns, and described the curtains as being touched by everyone and not cleaned well. Another resident’s room was observed not to have received basic daily cleaning, with dust and debris under the bed and heat register, dust on the dresser, a crumpled napkin on the floor near the bed, an overflowing trash can, and a discarded glove and gown tie on the floor near the trash can. This resident stated that no one had come in to clean their room the previous day or the day of the observation. These observations showed that routine cleaning tasks, such as trash removal, dusting, and floor cleaning, were not consistently performed in resident rooms. Interviews with staff revealed conflicting and unclear information about the frequency and scope of daily and deep cleaning. One staff member stated that no deep cleaning was being completed, that there was only one housekeeper per floor responsible for many residents, and that CNAs cleaned as needed after housekeeping left for the day. Another staff member initially stated that every room was deep cleaned daily, then clarified that downstairs rooms were deep cleaned daily and upstairs rooms weekly, and later stated the facility was working on a monthly deep cleaning schedule. This staff member also reported not knowing if window and privacy curtains were removable. Another staff member stated that two rooms per floor were deep cleaned each day and questioned the reliability of the deep clean log, noting that “anyone can check something off.” Review of QAPI minutes showed a plan to start a privacy curtain cleaning rotation, but no documentation of such a rotation was provided, and the facility’s own “Complete Room Cleaning” document referenced monthly discharge-level cleaning and checking curtains without evidence this was carried out as described.
Failure to Implement Enhanced Droplet Precautions and PPE for COVID-19
Penalty
Summary
The deficiency involves the facility’s failure to implement appropriate infection prevention and control practices, including hand hygiene, transmission-based precautions, and use of PPE, for a resident on Enhanced Droplet Precautions for COVID-19. Surveyors observed signage at the public entrance indicating active COVID-19 cases in the building and a sign on the resident’s door requiring an N95 mask, gown, gloves, and eye protection. A PPE cart outside the room contained eye protection, masks, and gloves, but no isolation gowns, and no PPE was observed inside the room or in the trash receptacle. On multiple occasions, staff entered and exited the resident’s room wearing only a face mask, without gowns, gloves, or eye protection, and no hand hygiene was observed before or after room entry. One staff member entered the resident’s room to deliver medications while the resident was in the shower, then immediately went into another resident’s room wearing the same mask and without performing hand hygiene. The resident reported being in isolation for 14 days after testing positive for COVID-19 and stated that staff did not always wear gowns or all the required isolation gear, suggesting inconsistent adherence to the posted precautions. Staff interviews confirmed lapses in practice and knowledge: one staff member acknowledged that PPE should have been worn but was not, another stated it had been quite some time since they had training, and a contracted staff member reported not receiving updated training on transmission-based precautions from either the agency since 2023 or the facility. This contracted staff member also had an incorrect understanding of when eye protection was required for Enhanced Droplet Precautions and did not understand when Enhanced Barrier Precautions would be used. The facility was unable to provide requested documentation of staff education on Enhanced Droplet and Enhanced Barrier Precautions by the end of the survey, despite having a written policy dated 9/13/25 requiring N95 or higher respirator, gown, gloves, and eye protection for conditions such as COVID-19, and CDC guidance specifying hand hygiene and full PPE for Enhanced Droplet Precautions.
Medications Left at Bedside Without Order or Safety Assessment
Penalty
Summary
The deficiency involves staff leaving medications at a resident's bedside for unsupervised self-administration without a physician order or completed safety assessment. During an observation, a resident with neuromuscular spasticity of both upper extremities, weak vocal quality, slowed speech, and generalized neuromuscular weakness was seen lying in a recliner with seven assorted capsules in a medicine cup on a table within reach. The medications were accessible without supervision. A staff member later stated she had entered the resident's room earlier and left the medications at the bedside while the resident was in the shower, and acknowledged the resident probably did not have a physician's order for self-administration of medications. Further review of the resident's electronic health record showed diagnoses of oropharyngeal dysphagia, dysarthria, anarthria, and conversion disorder with motor symptoms. The record contained no self-administration safety assessment or physician order authorizing self-administration of medications. A speech therapy note indicated the resident was permitted to have bread and was on a regular diet with a preference for rye bread, but there were no additional speech therapy notes or swallow evaluations documenting the resident's ability to safely swallow or self-administer medications. The facility did not provide any documentation of a medication self-administration safety assessment, speech therapy evaluation supporting safe self-administration, or a physician order for self-administration by the end of the survey, and the failure was noted to place the resident at risk for choking, aspiration, and medication errors.
Failure to Implement Physician-Ordered Physical Therapy Services
Penalty
Summary
The deficiency involves the facility’s failure to ensure that physician-ordered physical therapy services were implemented for one resident in accordance with professional standards of quality. Admission orders dated 12/23/25 included a physician’s order for physical therapy to evaluate and treat, and these admission orders were signed off by a nurse (NF2) on 1/1/26. However, review of the resident’s admission MDS with an ARD of 12/29/25 showed no therapy services documented in Section O0390, and a Census Details Report dated 3/23/26 confirmed the resident was never enrolled in therapy services at any time during the stay. The resident was later transferred to an assisted living facility on 2/10/26, per the request of NF1. Interviews with staff revealed that the facility’s process for initiating therapy orders was not followed or failed at some point. Staff member D explained that when therapy orders are included in admission orders, the admitting nurse is responsible for forwarding a copy to the therapy department so that the physical therapist can complete the initial assessment, and stated that the resident’s initial therapy order may have been missed or not forwarded, leaving therapy staff unaware of the order. Staff member H stated that when a new therapy order is received, a PT evaluation is typically completed within a couple of days and treatments are then carried out by PT assistants, but acknowledged that this resident did not receive the ordered services and could not explain how this occurred. NF1 confirmed by phone that the resident was admitted with therapy ordered but did not receive therapy during the stay. Reference to National Council of State Boards of Nursing standards indicated that nurses are responsible for implementing patient care orders unless there is a reason to question them.
Unsanitary Food Handling and Infection Control Failures in Dietary Services
Penalty
Summary
The deficiency involves failure of kitchen staff to handle and serve food in a clean and sanitary manner in accordance with professional standards and infection control practices. During a COVID-19 outbreak at the facility, two dietary staff members were observed working in the food preparation area without wearing infection control face masks. During breakfast meal service, one staff member assembling resident breakfast trays wore gloves but used the same gloved hands to handle trays, tray cards, food racks, and then cupped her hand over open juice glasses without changing gloves or washing/sanitizing her hands, moving between clean and contaminated tasks. Another staff member was not wearing gloves and used bare hands to grab link sausages, cut them, and place them on plates, as well as to grab muffins, move eggs around on plates, and touch the inside of cereal bowls and plate surfaces where food would be placed, without handwashing, sanitizing, or donning gloves. During an interview, another staff member stated that kitchen staff should never touch food with their bare hands, indicating that the observed practices were inconsistent with expected procedures. During lunch service, one staff member was observed cutting pizza and placing it on plates with bare hands, scraping beans from a serving spoon and moving them around on plates with bare hands, and placing buns on plates with bare hands. Another staff member cut a sandwich and placed it onto a resident’s plate with bare hands. These observations showed repeated failures by multiple dietary staff members to follow infection control precautions and sanitary food-handling practices during meal preparation and service for residents receiving food from the kitchen.
Failure to Provide Required Written Transfer and Bed-Hold Notices
Penalty
Summary
The facility failed to provide a written notice of the reason for a facility-initiated transfer or bed hold to a resident or the resident's representative. One resident was discharged from the facility to a local hospital, and review of the electronic medical record showed a discharge date but no transfer or bed hold notices. The resident did not return to the facility following this transfer. When surveyors requested the transfer and bed hold notice for this resident, the facility produced a document stating there was no bed hold present for the transfer on that date. During interviews, one staff member stated that residents who transferred to the hospital for urgent evaluation would sign a bed hold and transfer notice form, and that the nurse transferring the resident would complete it, but she did not know if a form was filled out for this resident. Another staff member stated that residents who transferred from the facility signed a transfer notice and a bed hold notice form, and that nurses would assist residents to sign if they were unable. Review of facility policies showed that written discharge or transfer notices, including the reason, effective date, and location, must be provided and a copy maintained in the clinical record, and that bed-hold notices must be provided in writing in advance and again at the time of transfer or within 24 hours for emergency transfers. These required notices and documentation were not present in the resident's record.
Failure to Provide Scheduled Bathing Assistance per Resident Preference and Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to provide assistance with activities of daily living (ADLs), specifically bathing, to a resident who was dependent on staff for bathing and had a stated preference for showers twice weekly on Tuesdays and Fridays. The resident reported very rarely receiving two showers per week and stated she did not feel clean due to the lack of showers. Review of the resident’s care plan dated 1/21/26 showed she was dependent on staff for bathing with assistance of one staff member. Review of bathing records from 12/1/25 through 2/26/26 showed the resident was scheduled for showers twice weekly but did not receive scheduled showers on multiple dates, resulting in 17 showers out of 24 opportunities over three months. The electronic medical record showed the resident went without a shower for more than six days on four occasions and once for 13 days between showers, supporting the resident’s claim of not receiving the preferred two showers per week. Staff interviews revealed that CNAs relied on shower schedules and a list at the nurse’s station to determine which residents were to receive showers, and that refusals were to be re-approached and, if persistent, documented on a shower refusal form with the resident’s signature. One staff member stated she was unsure if residents scheduled for evening showers had been completed and noted that residents scheduled for evening showers often requested showers the following day. Another staff member stated that if a resident refused a shower, a different CNA would offer it, and if refusal continued, a refusal sheet would be completed and signed by the resident. When the shower refusal notebook at the nursing station was checked, only one refusal form was present. The facility’s ADL policy dated 9/8/25 stated that residents receive assistance with ADLs, including hygiene and bathing, based on individual needs, preferences, and care plan goals, and that ADL assistance and resident response are documented in the medical record, but the documented shower frequency for this resident did not align with her care plan and stated preferences.
Delayed Delivery of Antiviral Medication for High-Risk COVID-19 Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide a prescribed antiviral medication in a timely manner to a resident with COVID-19. The resident had a chronic illness and was receiving chemotherapy for metastatic cancer. After the resident tested positive for COVID-19, the physician ordered Molnupiravir, an oral antiviral medication authorized for adults with mild-to-moderate COVID-19 who are at high risk for progression to severe disease. Nursing progress notes show that on the day after the positive test, staff documented that Molnupiravir was supposed to be delivered that morning, but by mid-afternoon it had not arrived from the pharmacy. Later that night, nursing documentation shows that Molnupiravir was finally administered when it arrived from the pharmacy, resulting in a two-day delay in starting treatment for an acute illness. During an interview, a staff member reported that prescription medications were delivered from an out-of-state pharmacy and that there were times when medications were not delivered timely. The staff member stated they had received verbal confirmation that the medication for this resident had been received, but when they returned to work the next day, it had not been delivered. The staff member also explained that although the facility had an Omnicell and access to a local satellite pharmacy, they were dependent on the pharmacy to restock medications, and this resident’s case was cited as an example of not receiving COVID-19 treatment medication in a timely manner. The facility’s pharmacy services policy required collaboration with the pharmacy to ensure medications are requested, received, and administered in a timely manner and that routine and emergency pharmacy services are available 24/7.
Improper Use of Hand Restraints by Untrained Staff Resulting in Resident Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure that staff received facility-specific restraint and abuse prevention training prior to providing resident care, resulting in the use of an unauthorized physical restraint on a resident. A staff member (Staff D) observed Resident #3, who had an ostomy and a surgical wound on the hip, becoming very anxious and agitated and digging at her surgical site and stoma to the point of causing bleeding. After administering PRN lorazepam and morphine and reassessing the resident 15–20 minutes later, Staff D noted that the resident continued to dig at her surgical site and stoma and became further concerned for her safety. At that point, Staff D attempted to protect the resident by wrapping washcloths and pillowcases around the resident’s hands to prevent her from continuing to dig at her ostomy site. One hand was already wrapped when another staff member (Staff E) entered the room and observed Staff D attempting to wrap the resident’s other hand. Staff E immediately stopped the process, informed Staff D that what he was doing could be considered a restraint and was not allowed in the LTC setting, and removed the washcloths from the resident’s hand. During this episode, the resident bit at her wrapped left hand and cracked one of her teeth. The facility’s investigation confirmed that this was an incident in which a well-intentioned staff member, attempting to protect the resident from self-harm, implemented an intervention that was not appropriate for the setting and constituted a physical restraint. Review of personnel files for Staff D and other agency staff showed that restraint and abuse prevention training had not been completed by the facility prior to them providing resident care and prior to the incident. This lack of required training and the subsequent use of an improvised hand restraint on the resident led to the identified deficiency related to improper use of physical restraints.
Failure to Investigate and Address Elopement After Unsupervised Off-Site Appointment
Penalty
Summary
The deficiency involves the facility’s failure to complete a thorough investigation and take corrective action after a resident with a known elopement risk left supervision during an off-site dental appointment. The resident had diagnoses including schizophrenia/schizoaffective disorder, major depressive disorder, and moderate cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 12. According to the resident’s family member, the resident experienced hallucinations and exhibited poor and impulsive decision-making, making him vulnerable when left unattended. The facility’s appointment calendar for the dental visit specifically documented in capital letters that staff were to stay with the resident due to elopement risk and noted that his sister would arrive shortly after the scheduled appointment time. On the day of the dental appointment, a staff member transported the resident and was aware that the resident was not to be left unsupervised. The staff member waited until the resident was escorted to the exam room, then left the office to pick up paperwork from another facility, believing the resident would be safe while with the dentist. When the staff member returned, dental staff reported that the resident had already left. The resident’s whereabouts were unknown for approximately one hour, during which time he left the dental office alone, obtained a taxi, and traveled to a relative’s home approximately two miles away. The facility-reported incident documented that the resident refused to return to the facility and expressed a desire to live on his own and to travel out of state to visit friends. Following the elopement event, facility leadership acknowledged that no Interdisciplinary Team (IDT) review, after-action plan, or full investigation was completed regarding the resident’s elopement from the dental office. Staff stated that aside from the facility-reported incident form, they did not document the sequence of events from the time the resident was left unsupervised at the dental visit to the time he was located, nor did they determine or document corrective actions. This lack of investigation and documentation occurred despite the facility’s written Elopement policy, which required the IDT to investigate elopement incidents, identify contributing factors and root causes, and document findings and recommendations in the medical record with updates to the plan of care as indicated.
Failure to Individualize Elopement Care Plan and Provide Supervision During Off-Site Appointment
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident at known risk for elopement had adequate, individualized care plan interventions and supervision to prevent elopement. The resident had a history of mental health problems, impaired decision-making, and expressed desires to leave the facility, including plans to travel to another state to visit friends who were deceased or incarcerated. An elopement/wandering risk evaluation completed in early September identified the resident as an elopement risk and recommended increased monitoring, staff notification, and care plan updates. The resident’s sister (POA) reported that the resident did better when compliant with medications and became more irrational and impulsive when he stopped taking them. She also reported, on multiple occasions, that the resident expressed anger about being placed in the facility and a desire to leave, including to visit friends in another state. Despite these known risks and repeated verbalizations of intent to leave, the resident’s care plan did not incorporate specific interventions discussed with the family, such as supervised walks, supervised medical appointments when the sister could not attend, or interventions tied to medication refusal and increased elopement risk. The care plan contained general wandering/elopement interventions (e.g., redirection, hourly monitoring, diversional activities, elopement risk assessments) but did not address the resident’s specific behaviors, his stated plan to travel out of state, or his sleep disturbances and nighttime pacing. Nursing progress notes documented the sister’s concerns about the resident’s ongoing desire to elope and resentment about being in the facility, as well as an incident where the resident attempted to sign himself out and leave the facility, but there was no corresponding update to the care plan to reflect these escalating behaviors. The facility also failed to provide routine behavioral monitoring for the resident’s elopement-related behaviors and did not have behavior monitoring orders in place for wandering or exit-seeking from September through mid-December, despite documentation of nighttime pacing and lack of sleep. On the day of the elopement from a dental appointment, the transport staff member was aware the resident was an elopement risk and that staff were expected to stay with such residents during outside appointments. The appointment calendar specifically noted that staff were to stay with the resident due to elopement risk. Nonetheless, the staff member left the resident unsupervised at the dental office to run an errand, and during this unsupervised period the resident left the office, called a taxi, and went to a relative’s home. The facility then treated the situation as if the resident were leaving against medical advice and did not complete an interdisciplinary after-action investigation or documented root cause analysis of the elopement. An updated elopement evaluation was not completed until four days after the resident’s return, and the post-readmission care plan remained largely generic, without incorporating the family-agreed stipulations or individualized interventions to prevent recurrence. The facility’s own policies required an elopement/wandering evaluation to be completed post-elopement, an IDT investigation with root cause analysis, and care plan updates after any incident involving unsafe wandering or elopement. Staff interviews confirmed that the expectation was to review and revise the care plan after an elopement and to conduct behavior monitoring for residents identified as elopement risks. However, for this resident, there was no documented IDT after-action plan, no timely post-elopement evaluation, and no documented care plan revisions that reflected the specific risks and conditions that had been identified by staff and family prior to and following the elopement. These omissions, combined with the failure to maintain supervision during transport to a medical appointment, led to the resident leaving unsupervised and constituted the cited deficiency in accident hazard prevention and supervision. The facility’s failure to address these concerns placed this resident at a continued risk of elopement and/or harm.
Failure to Investigate and Resolve Resident Grievances
Penalty
Summary
The facility failed to uphold and operationalize its grievance policy, resulting in multiple grievances from residents and their representatives not being investigated or resolved. Documentation was incomplete or missing for grievances, with no evidence of follow-up, investigation, or communication of outcomes to the complainants. Staff interviews revealed that grievances were often deprioritized, and some staff only investigated complaints if they suspected abuse, otherwise taking no further action. Grievances submitted through resident council meetings and grievance boxes were not consistently included in the official grievance binder, and many lacked required documentation such as investigation steps, findings, or resolution status. Several residents reported ongoing care concerns, including not being repositioned as required for pressure ulcer prevention, delayed response to call lights, and improper medication administration. Residents and staff described repeated complaints about care issues such as lack of showers, long call light response times, and being left wet overnight, with no evidence that these concerns were addressed. Some grievances involved allegations of staff causing injury during care, but these were not investigated as potential abuse or neglect, nor were they reported as required by facility policy. Facility records and interviews indicated a systemic breakdown in the grievance process, with staff acknowledging that grievances were not prioritized and often ignored. The facility's own policy required acknowledgment, investigation, and documentation of all grievances, including reporting of alleged abuse or neglect, but these steps were not followed. As a result, residents and their representatives did not receive responses or resolutions to their concerns, and there was no documentation of corrective actions or communication regarding the outcomes of their grievances.
Failure to Report Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to identify and report accusations of abuse and/or neglect by staff to the State Survey Agency for three of seven sampled residents. In one case, a resident complained about not being repositioned throughout the night, and a family member raised concerns regarding missed medication administration and catheter care. These concerns were documented in progress and physician notes, but staff confirmed that no report was made to the State Survey Agency regarding these allegations of neglect. Additionally, grievances were filed by two other residents: one reported being hurt by a night CNA during care, and another, who was being treated for a recently fractured arm, reported pain when a staff member pulled his arm during a transfer. Both of these allegations, which could indicate potential abuse or neglect, were not reported to the State Survey Agency as required by facility policy. Staff interviews confirmed that these accusations should have been reported and investigated, but this did not occur.
Failure to Investigate and Report Alleged Abuse and Neglect
Penalty
Summary
The facility failed to thoroughly investigate and report alleged violations of abuse or neglect involving three residents. One resident reported being hurt by a staff member during care, and another resident with a fractured arm complained that a staff member hurt his arm during a transfer. Grievance records for both residents did not show evidence that these events were investigated or reported to the State Survey Agency as potential abuse or neglect. Additionally, a third resident with pressure ulcers and a care plan requiring frequent repositioning complained of not being repositioned all night. This resident's family also raised concerns about missed administration of prescribed vaginal cream and lack of catheter care, despite physician orders for both interventions. Interviews with staff confirmed that these complaints and allegations were not reported to the State Survey Agency or investigated as required. The facility's policy mandates review and investigation of grievances, complaints, and allegations of abuse or neglect, but records and staff interviews indicated that these procedures were not followed for the incidents involving the three residents.
Failure to Maintain RN Coverage
Penalty
Summary
The facility failed to have a registered nurse (RN) on duty for at least eight consecutive hours a day, seven days a week, as required. This deficiency was identified through interviews and record reviews, revealing that on multiple occasions from July to October 2024, there was no RN scheduled for the required hours. Residents expressed concerns about the staffing levels, noting that it was sometimes difficult to be seen by a nurse due to their busyness. Staff interviews indicated that when an RN was not scheduled, the facility attempted to find replacements using a program called Clipboard or by having management staff cover the floor. Additionally, there were concerns about the accuracy of PBJ reporting, which is managed by a corporate person outside the facility.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure staff practiced appropriate use of personal protective equipment (PPE) during the care of residents on enhanced barrier precautions (EBP) in the 100 north hall. Observations revealed that no EBP signs were posted, and staff did not use gowns or gloves when providing care to residents with catheters, cholecystostomy tubes, or surgical wound dressings. Staff members were observed assisting residents with personal care and transfers without the necessary PPE, despite the presence of conditions that required EBP. Interviews with staff indicated a lack of awareness and communication regarding EBP requirements. Staff member I stated that there were no signs to designate the need for PPE, and the CNA staff did not share EBP statuses in their shift reports. Staff member D acknowledged that EBP would be required for residents with catheters, wounds, or other tubes, but staff member C was unaware of what EBP entailed. The facility's Transmission-Based Precautions Conventional Plan outlined the need for targeted gown and glove use during high-contact activities, but this was not being implemented effectively.
Deficient Antibiotic Stewardship Program
Penalty
Summary
The facility failed to maintain an effective antibiotic stewardship program, which is crucial for monitoring antibiotic use and infection surveillance. During an interview, a staff member expressed a lack of support in her role since November 2024, indicating that some healthcare providers in the facility do not adhere to McGreer's criteria when prescribing antibiotics. Instead, antibiotics were sometimes prescribed based on behavior or symptoms, and the staff member felt unable to influence the prescribing practices of doctors. This lack of adherence to established criteria for antibiotic use suggests a deficiency in the facility's antibiotic stewardship efforts. A review of the facility's infection control log for December 2024 revealed 20 infections, including wound, skin, lung, fungal, and urinary infections. Notably, seven of these were urinary tract infections, but only one had a documented urine culture and sensitivity test. The remaining six urinary tract infections were treated with antibiotics without such testing. Additionally, the facility did not track organisms for residents who came from the hospital on antibiotics, citing difficulty in obtaining lab results. The facility's document on antibiotic stewardship, last revised in October 2022, outlines the need for infection validation using McGreer's Criteria and routine review of culture and sensitivity reports, which was not consistently followed, leading to the identified deficiency.
Failure to Document and Administer Pneumococcal Vaccines
Penalty
Summary
The facility failed to ensure proper screening and documentation for influenza, pneumonia, and COVID-19 immunizations for residents. Specifically, three residents were not screened for pneumococcal vaccines, and there was no documentation of either vaccine administration or signed declinations. One resident had not received an updated pneumococcal vaccine since 2000, while two others had no records of receiving or declining the vaccine. During an interview, a staff member admitted to being unaware of her responsibility for immunizations and only ordered the vaccines after the surveyor's request. The facility's policy on pneumococcal immunization, revised in November 2024, outlines the need for resident education and vaccine administration unless contraindicated or refused, but this was not adhered to in practice.
Failure to Respect Resident's Request for Hospital Transfer
Penalty
Summary
The facility staff failed to respect a resident's rights by not following up on a request to be sent to the emergency room when the resident was not feeling well. The incident involved a resident who expressed feeling unwell and requested to go to the hospital. Despite the resident's request and low oxygen levels, the facility staff did not arrange for the transfer. Instead, a non-facility caregiver visiting the resident called an ambulance without notifying the facility, leading to the resident's transport to the hospital. Interviews with staff members revealed that the nurse on duty was aware of the resident's condition, and another staff member was present when the ambulance arrived. The facility's document on Resident's Rights emphasizes the resident's right to a dignified existence, self-determination, and participation in their treatment. However, the facility's inaction in this situation resulted in a failure to uphold these rights, as the resident's request for medical attention was not addressed by the facility staff.
Delayed Reporting of Neglect Allegation
Penalty
Summary
The facility failed to report an allegation of neglect involving a resident to the State Survey Agency within the required 24-hour timeframe. The incident involved a resident who was not feeling well and requested to be sent to the hospital, claiming neglect by the facility staff for not sending her. The incident occurred on December 30, 2024, but was not reported to the state until January 1, 2025, after an anonymous complaint was submitted through the facility's website. This delay in reporting was acknowledged by staff members who were aware of the incident but did not act promptly. The facility's policy on abuse, revised in July 2019, mandates immediate reporting of allegations of neglect to the Executive Director and the state agency. Despite this policy, staff members failed to report the incident in a timely manner. Internal communication showed that staff were reminded to follow up within 24 hours, yet the report was delayed. The failure to adhere to the reporting policy resulted in a deficiency being cited during the survey.
Failure to Monitor Resident's Oxygen Needs and Hospital Transfer
Penalty
Summary
A deficiency was identified in the facility's care for a resident who required monitoring for oxygen needs and potential transition to an acute care facility. The resident expressed feeling unwell and requested to go to the hospital, but the facility staff did not take immediate action. The resident's vital signs showed an oxygen saturation of 71%, which is critically low, yet the staff did not document any follow-up assessments or vital signs after the initial evaluation. The resident's non-facility caregiver eventually called an ambulance, and the resident was transported to the hospital. The facility's documentation policy requires that the medical record accurately reflect the resident's health status, including changes in condition and actions taken. However, the facility failed to provide documentation of follow-up assessments or actions taken in response to the resident's condition. This lack of documentation and failure to act promptly on the resident's request and low oxygen levels contributed to the deficiency identified by the surveyors.
Deficiencies in Oxygen Therapy Management and Equipment Labeling
Penalty
Summary
The facility failed to ensure that physician orders for oxygen therapy were present in the electronic health records (EHR) for two residents. During observations and interviews, it was found that one resident was receiving oxygen therapy without a documented physician order, and another resident had an oxygen concentrator in their room without a corresponding order in their medical record. Staff members expressed uncertainty about the necessity of having a physician order for oxygen therapy, and the facility did not have standing orders for oxygen. Additionally, the facility did not consistently label oxygen supplies and equipment with the date they were cleaned or changed for five residents. Observations revealed that residents' oxygen tubing, humidifiers, nebulizers, and CPAP equipment were not labeled with dates, and residents reported not seeing staff clean or label their respiratory equipment. The facility's policy required verification of a physician order before initiating oxygen therapy, but this was not adhered to, leading to deficiencies in the management of respiratory care.
Failure to Implement Resident Dietary Preferences and Timely Address Diet Changes
Penalty
Summary
The facility failed to properly implement and encourage dietary preferences for a resident, leading to a deficiency in care. The resident expressed difficulty swallowing dry or tough meats and preferred them with sauce or gravy. Despite these preferences being communicated during a care conference, the resident's diet order was changed without a swallowing assessment, and the resident was served minced pancakes, which she found inappropriate. Additionally, the resident's food often lacked gravy due to concerns about weight gain, which was not aligned with her preferences. The facility also lacked a consistent process to address therapeutic diet changes over the weekend. A staff member noted that diet orders were printed on Fridays, and any changes made after that time could be missed until the following Monday. This inconsistency was evident when the resident's diet order was not followed, as observed during breakfast, where the resident received cubed ham instead of minced ham, and scrambled eggs without cheese, contrary to the diet order. The resident also received milk despite expressing a preference against it due to a potential allergy. The facility's policy required changes in diet orders to be communicated to the Culinary Services department within two hours, but this was not adhered to. The resident's electronic health record showed a diet order change without accompanying documentation of a swallowing evaluation or physician communication. The lack of timely communication and adherence to dietary preferences and orders contributed to the deficiency, as evidenced by the resident's dissatisfaction and the staff's acknowledgment of the discrepancies.
Inadequate Legionella Prevention and Control Measures
Penalty
Summary
The facility failed to maintain water temperatures within the CDC's recommended range to prevent the growth of Legionella bacteria. The facility's policy required weekly temperature checks, but records showed that checks were conducted bi-weekly, with temperatures recorded within the favorable range for Legionella growth. Residents reported never seeing staff check water temperatures in their rooms, and observations revealed dirty toilets and sinks with residue that could harbor bacteria. Staff interviews revealed a lack of specific education on Legionella prevention, with staff unaware of symptoms beyond cough and pneumonia. Staff were not informed about the importance of cleaning water-related areas, such as sinks and toilets, to prevent Legionella. Documentation of staff education on Legionella was requested but not provided, indicating a gap in training and awareness among staff members. The facility's infection preventionist did not provide oversight or intervention when a resident was diagnosed with Legionella. Staff interviews indicated confusion about responsibilities and a lack of increased preventative measures following the diagnosis. The facility's Legionnaire Disease Outbreak Protocol required staff education and documentation, but these were not adequately implemented, contributing to the deficiency.
Inadequate Assistance and Smoking Hazards in LTC Facility
Penalty
Summary
The facility failed to provide adequate assistance to prevent injury for a resident, resulting in a fractured hip. The resident, who has a self-care performance deficit related to multiple sclerosis and requires assistance from two staff members for toilet transfers, was only assisted by one CNA during a transfer. This lack of proper assistance led to the resident falling and injuring his hip, necessitating surgery. The investigation into the incident was incomplete, as the investigation file was missing, and the education related to the incident was unavailable for review. Additionally, the facility did not ensure a safe environment free from smoking hazards. A resident was found with a marijuana vape pen in his bed, which he used regularly despite the facility's prohibition of medical marijuana use. Staff were aware of the resident's vaping but did not take action due to concerns about residents' rights and management's instructions. The presence of the vape pen posed a potential fire hazard, especially in a facility with oxygen in use. Furthermore, two other residents were found to be smoking on the facility's premises, contrary to the facility's smoke-free campus policy. These residents smoked outside by the dumpsters and in the parking lot, with staff being aware of their activities. The facility's policy requires residents and staff to refrain from smoking on the premises, but this was not enforced, creating additional safety hazards.
Failure to Conduct and Document Care Conferences
Penalty
Summary
The facility failed to conduct quarterly and annual care conferences and include residents and their representatives in the development and implementation of person-centered care plans. This deficiency was identified for seven residents who were part of the sample investigated. Interviews with residents and their representatives revealed that they were not invited to attend care conferences, and some were unaware of the opportunity to participate in their care planning. For instance, one resident expressed willingness to attend if invited, while another representative reported not being able to provide input on care concerns due to lack of invitation. The review of electronic health records (EHR) for the sampled residents showed that care conferences were not documented for several required periods, including quarterly and annual Minimum Data Set (MDS) assessments. For example, one resident had not had a care conference since March of the previous year, missing several quarterly MDS assessments. Another resident's representative, who lived far away, had arranged for monthly care calls but had not been included in care conferences since the resident's admission. This lack of documentation and participation was consistent across all sampled residents. Interviews with staff members revealed awareness of the delays and lack of care conferences. One staff member mentioned plans to conduct five care conferences a week to catch up, while another staff member acknowledged the backlog and had created a list of residents who had not had recent care conferences. Despite recognizing the issue during a mock survey, the facility did not provide a policy and procedure for care conferences when requested, indicating a systemic issue in managing and documenting care conferences.
Failure to Inform and Document Grievance Process
Penalty
Summary
The facility failed to ensure that residents were informed about the grievance process and how to file grievances, as evidenced by interviews with multiple residents who were unaware of grievance forms or the process. Several residents expressed that they did not know how to file a grievance and had to rely on external parties like the ombudsman or the State Survey Agency to voice their concerns. Additionally, some residents requested immediate assistance from staff to complete grievance forms, indicating a lack of accessible information and support within the facility. Staff interviews revealed that there was a lack of proper handling and documentation of grievances. Staff member A admitted to not being diligent in filling out grievances and preferred to address issues directly, which could lead to underreporting. Other staff members reported being instructed by a previous administrator not to file grievances or provide residents with the ombudsman's contact information, further complicating the grievance process. This lack of formal grievance handling was reflected in the facility's grievance logs, which showed minimal entries over several months, despite numerous complaints raised during resident council meetings. The facility's grievance policy required that complaints be acknowledged, investigated, and documented, with evidence maintained for at least three years. However, the facility failed to maintain proper documentation of grievances and investigations, as evidenced by the inability of staff to locate grievance logs or supporting documentation for concerns raised in resident council meetings. This failure to document and address grievances could potentially result in unrecognized and unaddressed issues related to resident care and services.
Failure to Report Abuse Allegations and Investigation Results
Penalty
Summary
The facility failed to report allegations of abuse and the results of an investigation to the State Survey Agency and Adult Protective Services. In one instance, a resident reported that a CNA had verbally abused her and physically restrained her in the bathroom. Despite the resident expressing fear and requesting counseling, the staff dismissed her claims as deflection and did not conduct an investigation or report the incident to the appropriate authorities. The facility's reporting system showed no record of this alleged abuse being reported. In another case, a resident suffered rib fractures following a fall, and the incident was initially reported to the State Survey Agency. However, the final investigation results were not submitted within the required timeframe. The facility's policy mandates that allegations of abuse and serious injuries be reported immediately, with investigation results submitted within five working days. The failure to adhere to these reporting requirements constitutes a deficiency in the facility's handling of abuse allegations and incident investigations.
Failure to Investigate and Report Alleged Abuse
Penalty
Summary
The facility failed to thoroughly investigate and prevent further potential abuse during an ongoing investigation of alleged abuse by staff towards a resident. The resident reported that a CNA had verbally abused her by calling her 'white trash' and that another resident had threatened her over a soda. Despite these allegations, the facility did not offer the resident counseling, and staff dismissed the incident as 'old news' during a care conference. The staff member interviewed admitted to not conducting a proper investigation into the resident's claims. The facility's records showed no reports of the alleged abuse to the State Survey Agency, nor was there a final 5-day summary sent after the investigation. The facility's policy requires immediate reporting of such allegations to the CEO and the state agency, which was not followed. Additionally, the resident's electronic health records did not reflect any notes of accusations of abuse by staff, indicating a lack of documentation and follow-through on the part of the facility.
Failure in Pressure Ulcer Prevention and Management
Penalty
Summary
The facility failed to prevent the development and worsening of pressure ulcers for two residents, resulting in significant deficiencies in care. Resident #6 developed a sacral pressure ulcer that progressed from Stage III to Stage IV over a period of time. The staff did not identify, report, or assess the resident's skin condition in a timely manner, nor did they implement necessary interventions to reduce skin pressure. Additionally, there were multiple missed dressing changes, and the resident experienced pain from the wound. The resident's condition was further complicated by inadequate wound care management, including instances where the resident was sent to the wound clinic without a dressing. Resident #15 developed a Stage III pressure ulcer as a result of a skin tear caused during care provision. The skin tear was attributed to improper use of a Hoyer lift sling, which was pulled from under the resident instead of rolling her side to side. The facility failed to assess the proper sling size and did not implement a care plan to prevent pressure ulcers, despite the resident being at risk. The resident's condition was exacerbated by the lack of timely wound care and assessment, leading to the progression of the skin tear to a Stage III pressure ulcer. The report highlights significant lapses in the facility's wound care management and pressure ulcer prevention strategies. Both residents experienced avoidable deterioration in their skin conditions due to the facility's failure to adhere to physician orders for wound care and to implement effective preventive measures. The deficiencies in care resulted in unnecessary pain and suffering for the residents, as well as a failure to provide the standard of care required to prevent and manage pressure ulcers effectively.
Failure to Follow Wound Care Protocols Leads to Stage IV Pressure Ulcer
Penalty
Summary
Licensed nursing and certified staff at the facility failed to adhere to professional standards of practice for wound care, resulting in a resident developing a pressure ulcer that deteriorated to a Stage IV. The resident, who was at high risk for pressure ulcers with a Braden score of 12, initially had intact skin upon admission. However, over the course of several months, the resident's condition worsened due to the staff's failure to follow physician orders for wound care treatments. Interviews with staff members revealed that while they were aware of the necessary interventions, such as turning and repositioning residents every two hours and reporting changes in skin condition, these practices were not consistently implemented. The review of the resident's medical records indicated multiple missed dressing changes, with a total of 17 missed instances documented. Specific dates were noted where dressing changes were not performed as ordered, including daily changes, every other day, and three times weekly schedules. Additionally, the resident arrived at the wound clinic on two occasions without any dressings on the wound, further highlighting the lack of adherence to prescribed wound care protocols. This failure to follow established wound care standards contributed to the deterioration of the resident's pressure ulcer.
Deficiencies in Care Planning for Pressure Ulcer Prevention and Pain Management
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for two residents, leading to deficiencies in their care. Resident #15, who was at risk for developing pressure ulcers as indicated by the Braden Scale, developed a Stage III pressure ulcer on her back due to improper handling with a mechanical lift. Despite the known risk and the development of wounds, the care plan for Resident #15 did not include problems, goals, or interventions for the prevention of pressure ulcers or for the treatment of existing ones. This oversight occurred even though the resident had started attending a wound clinic and was no longer receiving wound care from the facility staff. Additionally, Resident #6 experienced pain during wound dressing changes, yet the care plan failed to include interventions for pain management related to wound care. Although pain medication was ordered to be administered every six hours as needed, there was no clear documentation indicating whether the medication was given prior to dressing changes when the resident complained of pain. This lack of a specific pain management plan in the care plan contributed to the resident's discomfort during necessary medical procedures.
Inadequate Pain Management During Dressing Changes
Penalty
Summary
The facility failed to provide appropriate pain management for a resident during pressure ulcer dressing changes. The resident, who was readmitted after surgical repair of a hip fracture, had a skin condition that progressed to a Stage IV ulcer. Despite orders for pain medication to be administered 30 minutes prior to wound clinic appointments, the resident's medical records did not clearly document whether pain medication was given before dressing changes. Interviews with staff indicated that pain complaints were to be reported to the nurse, and pain medication should be administered prior to dressing changes if the resident complained of pain. However, the resident's care plan lacked interventions for pain management related to the wound and wound care, leading to inadequate pain relief during dressing changes.
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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