Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Northern Pines Rehabilitation And Nursing during CMS and state inspections, most recent first.
Unsecured Medications Found in Resident’s Nightstand: A resident was found keeping multiple medication bottles in a bedside drawer, including Tylenol, Motrin, Aspirin, Premarin, eye drops, and topicals. The resident said she took Tylenol nightly for knee pain and had told nursing staff about having her own bottle, but staff were unaware the medications were in the room and stated there was no assessment or order allowing self-administration.
Resident Height and Weight Posted in Public View: A resident's height and weight were posted outside the room door in public view, and the resident stated she had not given permission and found the posting unethical and disgusting. Staff said the posting was used as a CNA reminder for weights after admission, was sometimes left up, and permission was not specifically obtained before posting; the facility policy stated resident privacy must be maintained.
The facility failed to maintain evidence of Ombudsman notification for a resident’s hospital transfer. Staff said transfer and discharge notices were handled verbally and informally, and no documentation was available for the resident’s acute-care transfer. The facility policy required evidence that notice was sent to the Ombudsman and allowed emergency transfer notices to be provided when practicable.
Failure to Accurately Code Dementia on the MDS: A resident with a documented dx of unspecified dementia was observed having trouble operating his TV and radio and appeared confused about the controls. Staff stated dementia should have been included on the MDS if present, but the MDS coded Non-Alzheimer’s Dementia as No and did not reflect the dx until a later quarterly assessment, long after admission.
A resident admitted with multiple wounds had a baseline care plan that included general skin-integrity interventions, but it did not list wound care or wound treatment needs. Staff stated wounds should have been included, and the facility policy required the baseline care plan to be completed within 48 hours with the minimum info needed for care, including physician orders.
Incomplete care planning for splint use and dementia: A resident with left-sided hemiplegia and a near contracture of the left wrist was observed with the left hand flexed, while OT records noted prior splint use, increased tightness, and a new splint to be ordered; however, the care plan did not include the hand splint intervention. Another resident with a documented dementia diagnosis showed confusion and difficulty using a radio and TV, but the care plan did not include dementia or related interventions.
Delayed wound care orders and missed treatments: A resident admitted with multiple wounds had wound care orders entered late, and several ordered treatments were not documented as completed. Staff said the orders were assumed to be entered at admission, but the nurse responsible for entering the physician orders had forgotten to do so. The TAR showed some treatments were completed, while others for the coccyx and lower calf had no completion documentation.
Resident Refrigerator Not Monitored or Maintained: A resident’s personal refrigerator was found dirty, foul-smelling, and at 46 degrees Fahrenheit, with expired and improperly stored food inside, including a frozen pizza that was no longer frozen. Staff gave conflicting accounts of who was responsible for checking, cleaning, and logging the refrigerator, and one staff member stated the facility knew the resident had a refrigerator but did not have a process in place for its maintenance.
The facility failed to have a certified dietary manager or full-time dietician overseeing dietary services. Staff reported there was no certified manager, no full-time dietician, and no formal training process, while an interim staff member without certification was filling in for dietary oversight.
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.
Unsecured Medications Found in Resident’s Nightstand
Penalty
Summary
The facility failed to provide and maintain a safe environment for one resident when unsecured medications were found stored in the resident’s bedside nightstand. Resident #16 stated she took Tylenol every night for right knee pain and removed a bottle of Tylenol from the top drawer of her nightstand during an interview. She also stated she had told nurses a couple of days earlier that she had her own bottle of Tylenol, although later said she thought her daughter may have brought it in and was not sure. Staff members stated they were unaware the resident had Tylenol in her room. One staff member said she always offered Tylenol but the resident usually said she was okay, and speculated the resident may have obtained it while shopping on the facility bus. Another staff member stated she would notify another staff member if she found medications in a resident’s room. On observation, the bottom drawer of the resident’s nightstand was completely full of various medication bottles, including Tylenol, Motrin, Aspirin, Premarin, eye drops, and topicals. Staff members stated they did not know the medications were there, and one stated there was no assessment or order for the resident to self-administer medications. The facility policy stated a resident may only self-administer medications after the interdisciplinary team has determined which medications may be self-administered safely.
Resident Height and Weight Posted in Public View
Penalty
Summary
The facility failed to maintain the privacy of personal health information when a resident's height and weight were posted on a piece of paper outside the resident's room door in a public location. During observation, the resident's height and weight were seen posted in public view on the outside of the door, and the resident stated she had not given permission for the information to be posted. She said the information was not anyone's business, questioned whether the posting was ethical, and stated that no one had spoken to her about it. She also described the posting as sick and disgusting. Staff interviews showed the posting was used as a reminder for CNAs to obtain resident weights after admission, and staff stated the information was posted outside room doors and was sometimes left up, especially when new staff were working. One staff member stated permission was not asked before posting the height and weight, while another stated permission was assumed because the resident signed the consent to treat on admission. The facility policy titled Promoting/Maintaining Resident Dignity stated that the facility practices protecting and promoting resident rights and maintaining resident privacy.
Failure to Document Ombudsman Notification for Hospital Transfer
Penalty
Summary
The facility failed to maintain evidence of Ombudsman notification for a resident who was transferred to the hospital. Review of the resident’s hospital discharge summary showed the resident was admitted to the hospital on [DATE] and discharged on 9/29/25. During interviews, staff stated that Ombudsman notifications for transfers and discharges were handled verbally and informally, with one staff member stating the Ombudsman was notified twice per month and another stating notifications were made when the Ombudsman visited the facility. For the resident’s hospital transfer on 9/26/25, staff could not provide documentation showing that the Ombudsman had been notified. A request for evidence of the notification was made on 1/14/26, but no documentation was provided before the end of the survey. The facility’s policy titled, Transfer and Discharge (including AMA), stated that the facility would maintain evidence that notice was sent to the Ombudsman and that copies of notices for emergency transfers would be provided to the Ombudsman when practicable.
Failure to Accurately Code Dementia on the MDS
Penalty
Summary
The facility failed to comprehensively assess a resident’s diagnosis of dementia on the Minimum Data Set (MDS). Resident #2 had a documented diagnosis of unspecified dementia dated 4/16/24, and the resident was admitted to the facility on 1/30/24, but the diagnosis was not added on admission. During an observation and interview on 1/12/26, the resident was seen in his room attempting to turn off his radio and stated he was having trouble working both his television and radio, and he appeared confused about the buttons and what they controlled on the television. During an interview on 1/15/26, staff member G stated that a diagnosis of dementia should be on the MDS if the resident has a diagnosis of dementia and said resident #2’s dementia should have been included because it was present on admission. Review of the resident’s MDS with an ARD of 10/2/25 showed Section I, Active Diagnoses, coded I4800 Non-Alzheimer’s Dementia as “No,” indicating the assessment did not reflect dementia. The diagnosis was not documented on the MDS until the most recent Quarterly MDS with an ARD of 1/2/26, which was two years after admission.
Baseline Care Plan Missing Wound Care Interventions
Penalty
Summary
The facility failed to include wound care on the 48-hour baseline care plan for a newly admitted resident with multiple wounds, affecting 1 of 19 sampled residents. Resident #44 had been discharged from the hospital with “a lot of sores,” and the facility assessed the resident’s wounds on arrival. However, the baseline care plan initiated on 1/6/26 listed skin-integrity-related interventions such as nutrition, repositioning, weekly skin assessments, turning/repositioning assistance, bathing, peri-care, and heel protectors, but it did not include wound care or wound treatment interventions. During interviews, staff members stated that wounds should have been included on the baseline care plan and that the baseline care plan is completed by the two admission nurses to provide all information needed for resident care. A facility policy stated that the baseline care plan is to be developed within 48 hours of admission and include the minimum healthcare information necessary to properly care for a resident, including physician orders. The wound care needs for resident #44 were missed on the baseline care plan.
Incomplete Care Planning for Splint Use and Dementia
Penalty
Summary
The facility failed to comprehensively care plan and implement the use of a hand splint for a resident with left-sided hemiplegia and hemiparesis following a cerebral infarction, weakness, and generalized muscle weakness. During observation, the resident was seated in a wheelchair with a support platform mounted on the left side and her left hand was in a flexed position. Occupational therapy records showed she had previously worn a splint, had not been wearing it, and had increased generalized tightness in the left upper extremity with a near contracture at the wrist. OT documentation also stated that a new hand splint was to be ordered and fitted upon arrival, but the comprehensive care plan last reviewed on 10/29/25 did not include the intervention of a hand splint to prevent further contractures. The facility also failed to include a diagnosis of dementia and related interventions in another resident’s comprehensive care plan. During observation, the resident had difficulty operating a radio and reported trouble with the television, and he displayed confusion when discussing his medical conditions and facility stay. The medical record showed a diagnosis of unspecified dementia, mild, without behavioral disturbance, psychotic, mood disturbance, or anxiety, with an admission date of 4/16/24. The comprehensive care plan revised on 1/8/26 did not show the dementia diagnosis or any related interventions, despite staff stating that dementia should be care planned with interventions.
Delayed wound care orders and missed treatments
Penalty
Summary
The facility failed to provide necessary wound treatments and services for resident #44, who was admitted with multiple wounds, including sores on the feet, coccyx, heels, calves, and toes. During interviews, staff stated the resident had multiple wounds on admission and that the wounds had been assessed, with treatment orders including foam dressings, betadine to toe wounds, and pressure-reducing boots. Staff also stated the orders were thought to have been entered into the computer when the resident was admitted, but the nurse responsible for entering the physician orders had forgotten to enter them. Review of the electronic medical record showed all wound care orders were not entered until 1/12/26, several days after admission. The Treatment Administration Record showed some wound treatments were marked completed on 1/12/26 and 1/13/26, but other ordered treatments for the coccyx and lower calf had no documented completion checks. The record review showed the facility failed to enter wound care orders promptly and failed to treat resident #44's wounds for six days after admission. The facility policy stated wound treatments are to be provided in accordance with physician orders and documented on the TAR or in the electronic health record.
Resident Refrigerator Not Monitored or Maintained
Penalty
Summary
The facility failed to identify the need for and maintain processes for resident-owned refrigerators for 1 of 19 sampled residents, resident #31. During an observation and interview, resident #31 stated that someone used to check the refrigerator but had not done so in a while, and said the refrigerator smelled bad. The refrigerator in the resident’s room was observed at 46 degrees Fahrenheit, had a foul odor, and contained a mini pizza that was supposed to be frozen but was pliable and not frozen. The refrigerator did not have a freezer portion. Further observation showed the refrigerator contained an open bag of Cheetos, three small containers of Folgers coffee, a bottle of salad dressing, chocolate candy bars, a mini DiGiorno pizza in its original packaging, and other drinks and chips. The pizza had a best-by date of April 2025 and the box said to keep frozen, while the refrigerator remained at 46 degrees Fahrenheit and continued to have a foul odor. Staff interviews showed conflicting understanding about who was responsible for monitoring and cleaning resident refrigerators, with responses naming night nursing staff, activities, maintenance, housekeeping, or the family. One staff member stated the facility knew the resident had a refrigerator but did not have a process in place for its maintenance.
Lack of Qualified Dietary Leadership
Penalty
Summary
The facility failed to employ a certified dietary manager or a full-time dietician to oversee dietary department duties. During interview, staff member I stated the facility did not currently have anyone certified as the manager of the dietary department and did not have a full-time dietician. Staff member K stated they reported to an interim manager, staff member L, and were unsure whether she was certified; K also stated the previous manager’s last day was Christmas Eve and that there had never been a formal training process, describing staff as being “thrown to the wolves” when they start. Staff member L stated she had been filling in for dietary oversight since December 22nd, was in the hiring process for a dietary manager, had prior experience printing dietary tickets and some other duties, and was not certified.
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.
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What surveyors actually found near you
We read the citations issued around you in the last 12 months — including the immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Cut Bank
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Logan Health Care Center - Shelby | 23.4 mi | ★★★★★ | 0 | 0 |
| Logan Health - Conrad | 35.7 mi | ★★★★★ | 6 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.