Northern Pines Rehabilitation And Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in Cut Bank, Montana.
- Location
- 707 3rd St Se, Cut Bank, Montana 59427
- CMS Provider Number
- 275104
- Inspections on file
- 20
- Latest survey
- January 15, 2026
- Citations (last 12 mo.)
- 27
Citation history
Health deficiencies cited at Northern Pines Rehabilitation And Nursing during CMS and state inspections, most recent first.
The facility did not complete required background checks on several new and rehired staff members before they began working, allowing them to work shifts prior to the completion of these checks, contrary to facility policy and staff statements.
The facility did not report two separate abuse allegations involving a resident to the State Survey Agency within the required two-hour timeframe, and failed to submit investigation findings for incidents involving a missing wedding ring and resident-to-resident abuse. Delays were attributed to lapses in internal communication and frequent administrative changes, resulting in late or missing reports as required by facility policy.
The facility did not fully investigate several alleged abuse incidents, as only one staff interview was documented for each event, with no resident interviews or ongoing monitoring. Staff could not locate complete investigation records, and key personnel responsible for the investigations were no longer employed. The facility's actions did not meet its own policies requiring comprehensive abuse investigations and documentation.
Nursing staff administered lorazepam, a controlled substance, to a resident on three occasions after the medication had been discontinued and without a current physician order. The medication card was not removed from the medication cart, and the required destruction of discontinued narcotics by two nurses did not occur, contrary to facility policy and professional standards. The errors were not identified until over a month later.
A facility's inadequate fall prevention program led to multiple incidents involving three residents, resulting in injuries such as head lacerations and hematomas. Despite being at high risk for falls, residents experienced falls due to insufficient interventions, broken equipment, and lack of staff awareness of care plans. The facility failed to conduct thorough root cause analyses and implement appropriate interventions, contributing to the ongoing risk of falls.
The facility failed to ensure the director of food and nutrition services met CMS educational qualifications. A staff member was instructed to complete only part of the required training, and no specific policies for dietary manager training were available. The staff member had not completed the necessary certification, and no other staff had completed the dietary manager certification requirements.
Facility staff failed to wear hairnets in food service areas, as observed with staff members O and J, who were seen without hairnets while in the kitchen. Staff member J's braids hung over food during meal prep. Staff member I confirmed the requirement for hairnets, but dispensers were not available at all kitchen entrances.
The facility administrator failed to provide adequate oversight and training for the AIT and DON, affecting fall prevention protocols for three residents who experienced multiple falls without effective evaluation. Additionally, the facility lacked a certified Infection Preventionist and a qualified Dietary Manager, impacting care quality. Staff interviews revealed delays in training and incomplete qualifications, highlighting significant gaps in staff training and oversight.
The facility did not ensure the Infection Preventionist was certified through an approved program before assuming the role. After the previous Infection Preventionist resigned, a staff member was assigned to the role but had not completed the necessary training. Despite a request for certification documentation, none was provided by the survey's end.
The facility failed to implement a grievance policy with necessary contact information and did not provide a way for residents to file grievances anonymously. Residents expressed concerns about the lack of anonymity and fear of staff reprisal. Grievance forms were inaccessible to wheelchair users, and no anonymous submission system was in place.
The facility failed to ensure proper hand hygiene for residents before meals and during medication administration. Residents were not offered hand hygiene options before meals, and staff did not perform hand hygiene between resident contacts during medication administration, contrary to facility policy.
The facility failed to maintain an effective antibiotic stewardship program, leading to inadequate monitoring of antibiotic use for two residents. One resident was on multiple antibiotics over several months without effective resolution of a urinary infection, and another was kept on antibiotics despite negative culture results. Staff interviews revealed a lack of familiarity with antibiotic management protocols.
The facility failed to ensure call lights were within reach for three residents, leading to a deficiency in care. A resident's call light was found on the floor, another's was clipped behind the bed, and a third resident's call light was not offered after medication administration. Staff acknowledged the issue, and facility policy requires call lights to be accessible.
Two residents were involved in incidents that were not initially identified as potential abuse by the facility's IDT. The first incident involved a verbal altercation after their wheelchairs became entangled, and the second involved one resident kicking the other's wheelchair. These incidents were documented but not reported or investigated as abuse, contrary to the facility's policy.
The facility failed to report abuse allegations within the required 24-hour timeframe for two residents involved in separate incidents. The incidents were not initially identified as potential abuse by the IDT and were only reported after an audit. Additionally, the facility did not submit investigation results within the required five working days for another resident who reported rough handling by CNAs, citing difficulties with the reporting portal.
The facility failed to accurately complete MDS coding for two residents, leading to discrepancies in their medical records. One resident's MDS did not reflect the administration of an anti-psychotic medication, despite physician orders and MAR indicating its use. Another resident's MDS inaccurately indicated antibiotic use, with no supporting orders or administration records. These errors highlight a failure in ensuring accurate resident assessments.
A facility failed to update a resident's care plan to address anxiety management. The resident reported significant anxiety, and a staff member could not identify non-pharmacological interventions used. The care plan lacked documentation of anxiety as a focus area, non-pharmacological interventions, and details of pharmacological treatments and side effects, despite the resident being prescribed medications for anxiety.
A facility failed to meet professional standards by administering insulin without priming the pen, resulting in a resident receiving 2 units less than prescribed. Staff member H, while orienting another staff member, administered insulin without priming, contrary to standard practice and manufacturer's instructions. This oversight was confirmed by another staff member and a review of the manufacturer's guidelines.
A facility failed to complete a discharge summary for a resident, lacking a recapitulation of the stay and a post-discharge plan of care. Staff interviews revealed that nurses were responsible for this task, but a review of the resident's EHR showed no such documentation. Despite a request for the missing documents, none were provided by the survey's conclusion.
A resident was prescribed an antibiotic pending urine culture results. Despite negative results, the resident continued on the antibiotic for eight days without documented rationale. A staff member was unaware of the continued administration post-negative culture.
The facility failed to implement a gradual dose reduction for a resident's fluoxetine medication and inadequately monitored another resident's use of psychotropic medications, leading to adverse effects. A resident continued receiving fluoxetine despite a recommendation for dose reduction, while another was prescribed quetiapine without discontinuing alprazolam, resulting in low blood pressure and other symptoms. The facility did not provide adequate rationale or monitoring for these medications.
The facility failed to provide dental services for two residents, one with severe cognitive impairment and another with missing teeth. Both residents reported not being offered dental care, and observations confirmed poor oral hygiene. Staff interviews revealed no scheduled dental appointments and a lack of a specific dental services policy.
The facility failed to provide the required SNF ABN, Form CMS-10055, to two residents who received Medicare Part A skilled services. A staff member admitted that the facility had not been completing these forms upon discharge from skilled care services and could not explain the reason for this omission. A review of records showed that the facility did not complete the SNF ABN forms for residents whose Medicare Part A skilled services ended, indicating a systemic issue in notifying residents of their Medicare coverage and potential liability for services not covered.
The facility was found to be sharing nursing staff between the nursing home and the connected assisted living facility without proper scheduling and coding of accrued time on records. This practice resulted in the failure to ensure that licensed nurses were always working in the nursing home. Staff interviews and document reviews revealed that nursing staff would go to the assisted living facility to bring meals and medications to the remaining resident, without clocking out or changing their pay code. The nurses' schedule showed only one nurse scheduled to work a shift at a time in the nursing home.
Failure to Complete Timely Background Checks on New and Rehired Staff
Penalty
Summary
The facility failed to complete required background checks on six employees prior to their start dates, as evidenced by interviews and record reviews. Staff interviews revealed that background checks are supposed to be completed before new hires begin working, with no exceptions. However, it was confirmed that some employees, including those rehired, worked shifts before their background checks were completed or without a new background check being conducted upon rehire. Documentation showed significant delays between hire dates and the completion of background checks for several staff members. Review of facility policies indicated that background and criminal checks are to be initiated within two days of an employment offer and completed prior to employment. Despite this, employee files demonstrated that these procedures were not consistently followed. The issue was acknowledged by staff, who noted that under previous leadership, employees sometimes started work before the necessary checks were completed, and that this had been a recurring problem in the past.
Failure to Timely Report and Submit Findings for Abuse and Theft Allegations
Penalty
Summary
The facility failed to report two separate allegations of abuse involving a resident to the State Survey Agency within the required two-hour timeframe. In one instance, an alleged incident of verbal abuse between a staff member and a resident was not reported promptly. In another case, an allegation of staff-to-resident abuse was also not reported within the mandated period. Staff interviews revealed delays in internal communication, with staff waiting for responses from administrative personnel before reporting incidents, and some staff not immediately notifying administrative staff upon learning of the allegations. The facility's policy requires immediate reporting, but this was not followed in these cases. Additionally, the facility did not submit investigation findings to the State Survey Agency for three residents involved in separate incidents. One incident involved a missing wedding ring, and another involved an allegation of resident-to-resident abuse. The findings for these incidents were either not submitted or were submitted significantly late, with one report delayed by 13 business days. Staff interviews indicated that frequent changes in administration and issues with reporting and investigating incidents contributed to these failures. Facility policies reviewed require timely reporting and submission of findings, but these procedures were not adhered to in the cited cases.
Failure to Conduct Thorough Abuse Investigations
Penalty
Summary
The facility failed to conduct thorough investigations into multiple alleged abuse incidents involving several residents. In each case, the documentation showed that only one staff interview was conducted, with no resident interviews or evidence of ongoing monitoring after the incidents. Specific events included a resident-to-resident physical altercation in a shared room, a confrontation in the dining room where one resident struck another with a clothing protector, and a verbal altercation in a resident's room. In all instances, the facility's investigation records were incomplete, lacking interviews with all involved parties and failing to document follow-up actions or monitoring. Interviews with staff revealed that while some believed additional interviews had been conducted, they were unable to locate the relevant documentation. Key staff members responsible for the investigations were no longer employed at the facility, and the available records did not meet the requirements outlined in the facility's abuse investigation policies. These policies required immediate and comprehensive investigations, including interviews with all involved individuals and thorough documentation, which were not followed in these cases.
Controlled Substance Administered Without Current Physician Order
Penalty
Summary
Nursing staff failed to follow professional standards for medication administration by administering a controlled substance, lorazepam, to a resident without a current physician's order on three separate occasions. The resident had a documented order for lorazepam 0.5 mg by mouth at bedtime for anxiety disorder, which was set to be discontinued after a specified date. Despite the discontinuation, the medication was administered on three dates following the order's expiration, as evidenced by the Medication Administration Record and the Controlled Substance Log. Interviews with staff confirmed that the medication card was not removed from the medication cart after discontinuation, and the required destruction of discontinued narcotics by two nurses did not occur. Staff interviews revealed a lack of adherence to facility policy and professional standards, as staff members acknowledged that medications should not be administered without a current order and that discontinued narcotics should be promptly removed and destroyed. The errors were not identified by the facility until over a month after the last administration, as documented in a misappropriation report. Facility policies and training documents reviewed clearly stated the necessity of following physician orders and proper procedures for handling discontinued controlled substances, which were not followed in this instance.
Failure in Fall Prevention Program Leads to Resident Injuries
Penalty
Summary
The facility failed to effectively implement a fall prevention program, leading to multiple incidents involving three residents. Resident #25 experienced several falls, including one in the bathroom that resulted in a head laceration requiring staples and an overnight hospital stay. Despite being at high risk for falls, interventions such as grip tape, grip socks, and call light education were insufficient. The resident's lift recliner was broken for an extended period, and staff were unaware of a toileting program meant to assist the resident, contributing to the falls. Resident #7, who had severe cognitive impairment and was at high risk for falls, was found in a precarious situation in her room. The call light was out of reach, and the resident was attempting to maneuver around obstacles, leading to a fall that resulted in a head laceration and other injuries. The care plan lacked specific interventions for dressing assistance, and the resident's needs for assistance with mobility and transfers were not adequately addressed. Resident #27 also experienced multiple falls, including sliding out of a wheelchair and off a mattress, resulting in injuries such as a hematoma and a bloody nose. The call light was out of reach, and the resident's care plan did not include specific interventions for assistance with daily activities. The facility's failure to conduct thorough root cause analyses and implement appropriate interventions contributed to the ongoing risk of falls for these residents.
Deficiency in Dietary Manager Training
Penalty
Summary
The facility failed to ensure that the director of food and nutrition services met the educational qualifications required by CMS for a food service director. This deficiency was identified through interviews and record reviews. During an interview, a staff member revealed that another staff member instructed him to complete only the first eight-hour training course and to delay the 16-hour training course. Another staff member confirmed that there were no specific policies for dietary manager training requirements, and the facility relied on CMS guidelines. It was further revealed that the staff member in question had not completed the necessary training in the Food Service Manager program, having only completed the initial eight hours and was unaware of the requirement to complete the second part. Additionally, no other staff in the facility had completed the dietary manager certification requirements. A review of the employee file showed that the staff member was hired on 8/28/24 and had not completed the dietary manager certification training.
Failure to Wear Hairnets in Food Service Areas
Penalty
Summary
The facility staff failed to adhere to professional standards for food service safety by not wearing hairnets in food service areas. During an observation, staff member O was seen without a hairnet while walking through the kitchen as the cook was preparing meatballs. Similarly, staff member J was observed not wearing a hairnet while stocking near the prep table and later while prepping meal trays, with her braids hanging over the food. Further observations revealed that staff member J continued to work in the kitchen without a hairnet, with her braids nearly touching the trays as she bent over. An interview with staff member I confirmed that all staff entering the kitchen were required to wear hairnets, which were available in the top drawer of his desk. However, staff from other departments entered the kitchen from different doors, and hairnet dispensers were not yet available at those entrances. The facility's policy on preventing foodborne illness required hairnets or caps to prevent body hair from contacting exposed food.
Deficiencies in Oversight, Training, and Staff Qualifications
Penalty
Summary
The facility administrator failed to provide adequate oversight and training for the Administrator in Training (AIT) and the Director of Nursing (DON) regarding the responsibilities of the interdisciplinary team (IDT) in conducting reviews and processes, as well as in executing a performance improvement project related to the fall prevention protocol. This deficiency affected three residents who experienced multiple falls without effective evaluation of the root causes by the IDT. For instance, one resident sustained 12 falls, including a significant fall that required hospitalization, yet the care plan was only minimally revised. Another resident with severe cognitive impairment had no fall prevention plan until after multiple falls, and a third resident experienced six falls with no IDT notes until months later. Staff interviews revealed delays in fall prevention training and a lack of clear processes for fall management. Additionally, the facility failed to employ a certified Infection Preventionist and a qualified Dietary Manager, which could potentially affect any resident. Staff interviews indicated that the Infection Preventionist was unfamiliar with specific antibiotic management protocols and faced challenges in obtaining laboratory results. Furthermore, the Dietary Manager had not completed the necessary certification requirements, and no other staff had fulfilled these qualifications. These deficiencies highlight significant gaps in staff training and qualifications, impacting the facility's ability to provide adequate care and oversight.
Infection Preventionist Lacks Required Certification
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist was qualified through an approved certification program before assuming the role. This deficiency was identified during interviews and record reviews conducted by surveyors. Staff member A reported that the previous Infection Preventionist had resigned approximately one week prior, and staff member C was in the process of taking the necessary training class but had not yet completed it. Staff member C confirmed that she had been in the role for about one week and was still learning, without having completed the required training. A request for the Infection Preventionist's certificate of training was made, but no documentation was provided by the end of the survey.
Deficiency in Grievance Policy and Accessibility
Penalty
Summary
The facility failed to develop and implement a comprehensive grievance policy that included the name and contact information for the grievance official. Additionally, the facility did not provide a means for residents to file grievances anonymously. This deficiency was observed in four of the eighteen sampled residents. During interviews, residents expressed concerns about the lack of anonymity in the grievance process and the fear of staff reprisal if they filed complaints. The facility's grievance forms were only available at standing shoulder level near the nurse's station, making them inaccessible to residents in wheelchairs. Staff member C confirmed that there was no system in place for residents to submit grievances anonymously, as there were no grievance return boxes available on any facility unit. The facility's policy, dated April 2008, stated that residents had the right to file grievances anonymously, but the policy did not include the necessary contact information for the grievance official. This lack of accessibility and anonymity in the grievance process contributed to the residents' reluctance to voice their concerns.
Inadequate Hand Hygiene Practices in Dining and Medication Administration
Penalty
Summary
The facility failed to ensure proper hand hygiene practices were followed for residents before meals and during medication administration. During an observation in the dining room, residents were not offered the option to clean their hands before receiving their meals. Staff interviews revealed that hand hygiene was often forgotten, and there was no alternative method provided for residents, especially those who are wheelchair-bound, to clean their hands in the dining room. The facility's policy on hand hygiene for residents was reportedly the same as for staff, but it was not being consistently implemented. Additionally, during medication administration, staff member H did not perform hand hygiene between resident contacts for four out of five observed medication administrations. This was contrary to the facility's hand hygiene policy, which required hand hygiene before and after resident contact to prevent infection. The facility's document on hand hygiene, dated August 2014, indicated that hand hygiene products and supplies should be readily accessible to encourage compliance, but this was not observed in practice.
Inadequate Antibiotic Stewardship Program
Penalty
Summary
The facility failed to maintain an effective antibiotic stewardship program, as evidenced by inadequate monitoring of antibiotic use for two residents. One resident, with a history of urinary infections and a suprapubic catheter, reported being on multiple antibiotics over several months without effective resolution of the infection. The resident's medical records showed a series of antibiotic prescriptions from May to October, with corresponding urine culture results indicating various sensitivities. However, there were no follow-up urine culture results in the resident's electronic health record, and medication regimen reviews failed to show any pharmacist recommendations regarding antibiotic use. Another resident was prescribed an antibiotic pending urine culture results, which later returned negative for infection. Despite this, the resident remained on the antibiotic for eight days. Interviews with staff revealed a lack of familiarity with specific antibiotic management protocols and difficulty in obtaining urine culture results. The facility's infection prevention and control program document indicated that the infection preventionist was responsible for ensuring antibiotics were used according to best practice standards, but this was not effectively implemented.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that call lights were within reach for three residents, leading to a deficiency in resident care. During an observation and interview, it was found that Resident #7's call light was on the floor under her bed, and she was unable to locate it. Similarly, Resident #27's call light was clipped to the wall behind his bed, and he was also unable to state its location. These observations indicate that the residents did not have immediate access to their call lights, which are essential for communicating their needs to the staff. Resident #25 experienced multiple instances where the call light was not within reach. During an observation, the call light was clipped to the wall behind his bed while he was sitting in a recliner, and staff did not offer it to him after administering medication. On another occasion, the call light was placed on a pillow on the bed, out of reach for Resident #25, who was again in his recliner. Staff member M acknowledged that the call light was not within reach, and staff member C confirmed that call lights should always be accessible to residents. The facility's policy, dated October 2010, emphasizes the importance of having call lights within easy reach for residents in bed or confined to a chair.
Failure to Identify and Report Resident Abuse
Penalty
Summary
The facility failed to protect residents from verbal and physical abuse by other residents, specifically involving two residents. The incidents occurred on two separate occasions, where the first incident involved a verbal altercation after the residents' wheelchairs became entangled, and the second incident involved one resident kicking the rubber bumper of the other's motorized wheelchair. These incidents were documented in the electronic health records but were not initially identified as potential abuse by the Interdisciplinary Team (IDT) during their review of progress notes. The IDT, responsible for reviewing resident progress notes daily, except on weekends, did not recognize these interactions as potential abuse, leading to a failure in reporting and investigating the incidents as required by the facility's abuse policy. The policy mandates immediate reporting of any suspected abuse, neglect, or mistreatment. Despite the documentation of these incidents, the IDT concluded that the interactions did not constitute abuse and thus did not report them to the appropriate authorities, resulting in non-compliance with the facility's abuse prevention protocols.
Failure to Timely Report Abuse Allegations and Investigation Results
Penalty
Summary
The facility failed to report allegations of abuse to the State Survey Agency within the required 24-hour timeframe for two residents involved in incidents on separate occasions. The incidents, which occurred on 9/14/24 and 9/17/24, were not initially identified as potential abuse by the Interdisciplinary Team (IDT) during their daily review of progress notes. It was only after staff member P conducted an audit of the resident progress notes that the interactions were identified as potential abuse and subsequently reported on 10/14/24 and 10/15/24, respectively. The facility's abuse policy mandates that all alleged violations involving abuse be reported immediately, but no later than 24 hours if the events do not result in serious bodily injury. The delay in reporting was attributed to the IDT's failure to recognize the incidents as potential abuse during their initial review. Additionally, the facility did not submit the results of an investigation within the required five working days for another resident who reported rough handling by two CNAs. The investigation results, due by 9/24/24, were submitted late on 9/26/24. Staff member B acknowledged awareness of the five-day submission requirement but cited difficulties with the reporting portal and a lack of training as reasons for the delay. The facility's abuse policy requires that the results of all investigations be reported to the State Survey Agency within five working days of the incident.
Inaccurate MDS Coding for Medications
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) coding for two residents, leading to discrepancies in their medical records. For one resident, there was a failure to document the administration of an anti-psychotic medication, aripiprazole, during the observation periods of both the Annual and Quarterly MDS assessments. Despite physician orders and Medication Administration Records (MAR) indicating the resident was receiving aripiprazole for major depressive disorder, the MDS did not reflect this. The nurse responsible for the MDS coding was no longer employed at the facility, and the reason for the error could not be determined. In another case, the MDS inaccurately indicated that a resident was on antibiotics, despite no such orders or administration being recorded in the resident's Electronic Health Record (EHR) or MAR. The resident also confirmed during an interview that she was not aware of being on any antibiotics. These inaccuracies in MDS coding highlight a failure in ensuring accurate resident assessments, which are crucial for appropriate care planning and regulatory compliance.
Failure to Revise Care Plan for Anxiety Management
Penalty
Summary
The facility failed to revise an individualized comprehensive care plan to address the current management and interventions for a mental health diagnosis for one of the sampled residents. The resident expressed experiencing significant anxiety and worry, describing herself as a long-time worrier. During an interview, a staff member was unable to identify any non-pharmacological interventions that had been attempted to assist the resident with her anxiety. A review of the resident's electronic health record indicated that she was prescribed alprazolam, sertraline, and quetiapine for anxiety management. However, the care plan, which was last updated the day before the interview, did not include anxiety as a focus area, nor did it document any non-pharmacological interventions or the pharmacological treatments and their potential side effects.
Failure to Prime Insulin Pen Before Administration
Penalty
Summary
The facility failed to meet professional standards of practice by administering insulin using a pen without priming it first. During an observation, staff member H, who was orienting staff member N, was seen attaching a needle to an insulin detemir pen and administering 10 units to a resident without priming the pen with 2 units of insulin as required. Staff member N acknowledged that priming was standard practice and observed the failure to prime. Staff member C confirmed that priming insulin pens was expected of all nurses and was considered standard practice according to the manufacturer's instructions. A review of the manufacturer's instructions for the insulin detemir pen indicated that priming with a two-unit setting was necessary to ensure proper dosing.
Failure to Complete Discharge Summary and Plan of Care
Penalty
Summary
The facility failed to complete a discharge summary for a resident, which should have included a recapitulation of the resident's stay and a post-discharge plan of care. During interviews, staff members indicated that nurses were responsible for preparing the discharge summary at the time of a resident's discharge. However, a review of the electronic health record (EHR) for the resident in question revealed no documentation of the required recapitulation or post-discharge plan. Despite a request for the discharge summary and recapitulation of stay, no additional documentation was provided by the end of the survey.
Unnecessary Antibiotic Administration
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications. A resident was prescribed an antibiotic pending the results of a urine culture. Despite the urine culture results being negative for infection, the resident continued to receive the antibiotic for a total of eight days. The electronic health record (EHR) for the resident did not contain any prescriber rationale or indication for the continued use of the antibiotic. During an interview, a staff member stated she was unaware that the resident had been given an antibiotic after the negative urine culture.
Failure to Implement Gradual Dose Reduction and Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure residents were free from unnecessary psychotropic medications, as evidenced by two specific cases. In the first case, a resident was due for a gradual dose reduction of fluoxetine, as recommended by the pharmacist and agreed upon by the physician. However, the resident continued to receive the medication for several months until the issue was identified by a surveyor. This indicates a failure in implementing the gradual dose reduction process as per the facility's protocol. In the second case, a resident with anxiety was prescribed quetiapine in addition to existing medications, including sertraline and alprazolam, without discontinuing the latter. The addition of quetiapine led to adverse effects such as low blood pressure, lethargy, and dizziness, which were not adequately monitored or addressed. The facility's records did not provide a sufficient rationale for the use of quetiapine, especially given the resident's cardiovascular issues, and the potential interactions and side effects were not properly considered or documented.
Failure to Provide Dental Services
Penalty
Summary
The facility failed to provide necessary dental services for two residents, leading to a deficiency. Resident #7, who has a severe cognitive impairment with a BIMS score of 6, reported not being offered dental services. During an observation, a thick white plaque and a strong foul oral odor were noted. Her care plan indicated she had top dentures and missing bottom teeth, but there was no record of dental appointments. Similarly, Resident #25, who has many missing teeth and no dentures, stated he had not been offered dental care services either on-site or off-site. His care plan included an oral care routine, but no dental appointments were scheduled. Staff interviews confirmed the absence of scheduled dental appointments for both residents and revealed that the facility lacked a specific policy for dental services.
Failure to Provide SNF ABN Forms to Residents
Penalty
Summary
The facility failed to provide the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN), Form CMS-10055, to two of the three sampled residents who received Medicare Part A skilled services. During an interview, a staff member admitted that the facility had not been completing the SNF ABN forms when residents were discharged from skilled care services and was unable to explain the reason for this omission. A review of the records for two residents revealed that the facility did not complete the SNF ABN forms for residents whose Medicare Part A skilled services ended on specific dates, indicating a systemic issue in the facility's process for notifying residents of their Medicare coverage and potential liability for services not covered.
Deficient Staffing Practices in Nursing Home
Penalty
Summary
The facility was found to be sharing nursing staff between the nursing home and the connected assisted living facility without proper scheduling and coding of accrued time on records. This practice resulted in the failure to ensure that licensed nurses were always working in the nursing home. Staff interviews revealed that there was no specific policy for staffing the nursing department, and the facility had recently hired a medication aide to assist with the increased workload. Observations and interviews indicated that nursing staff would go to the assisted living facility to bring meals and medications to the remaining resident, without clocking out or changing their pay code. This practice was a recent change due to the assisted living facility losing two of its three residents, and the nursing home nurses did not receive breaks during night shifts or weekends because there was only one nurse on duty at a time. Review of the nursing staff timecards for April 2024 showed no separate time punches, shifts, or codes for nursing staff working in the nursing home and assisted living. Additionally, the Daily Nursing Staff Posting and Census documents for March and April 2024 included the assisted living resident in the nursing home census. The nurses' schedule for these months showed only one nurse scheduled to work a shift at a time in the nursing home. Staff members were unaware of the requirements for not sharing nursing staff between the connected nursing home and assisted living, leading to the deficient practice that had the potential to affect any resident needing assistance in the nursing home.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
