Park Place Transitional Care And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Great Falls, Montana.
- Location
- 1500 32nd St S, Great Falls, Montana 59405
- CMS Provider Number
- 275030
- Inspections on file
- 26
- Latest survey
- August 6, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Park Place Transitional Care And Rehabilitation during CMS and state inspections, most recent first.
A resident admitted with intact sacral skin developed a Stage III pressure ulcer that progressed to Stage IV, with healing not achievable. Despite interventions like an air mattress, repositioning, and wound care, documentation showed inconsistent repositioning, missed dressing changes, and incomplete wound assessments. The care plan lacked specific details about the wound, and pain management was not consistently provided before treatments, contributing to the ulcer's deterioration.
Surveyors found that food items in the kitchen were not properly labeled, dated, or discarded by their use by dates, and some were left uncovered or unlabeled. Additionally, refrigerator and freezer temperatures were not being monitored as required by facility policy. These failures may affect any resident receiving food from these storage areas.
The facility did not maintain a homelike environment by failing to control strong, persistent urine odors in a hallway, as observed over several days. Two residents and their visitors were affected, with one resident's family expressing concern about the overwhelming smell and the negative effects of excessive odor-masking sprays. Residents and families attempted to address the odor themselves, but the malodor remained present.
Contracted staff drew blood from a resident in a dining area without following proper infection control protocols, and facility staff did not provide additional training or enforce guidelines. For residents on droplet and contact precautions, required signage and PPE placement were not maintained, and staff entered rooms without appropriate PPE. In the kitchen, staff failed to change gloves or wash hands between handling soiled items and food, violating facility hygiene policies.
A resident who valued choosing her own clothing was not assisted in obtaining enough properly fitting clothes, resulting in her repeatedly wearing the same ill-fitting shirt and becoming distressed. Staff did not retrieve her personal clothing from her previous residence, and the facility's spare clothing did not fit, contrary to policy requiring residents to be dressed according to their preferences.
A resident with ongoing vision difficulties was not provided timely access to an eye doctor, despite repeated requests and documented need. Staff were aware of the resident's complaints and the lack of effective glasses, but no appointment was scheduled and transportation was not arranged, contrary to facility policy.
A resident with a history of neurogenic bladder and paraplegia, who previously managed his condition with intermittent self-catheterization, was admitted with an indwelling catheter. Despite a physician order for cognitive and self-catheterization assessment, the facility did not complete the evaluation or provide necessary supplies, leaving the resident with the indwelling catheter and without the opportunity to regain independence.
A resident with a history of stroke and new dialysis needs exhibited moderate depression and expressed interest in mental health counseling, but was not provided with behavioral health services or referrals. Staff recognized the resident's depressive symptoms, yet there was no documentation of follow-up or specific interventions, despite facility policy requiring person-centered behavioral health care.
A facility failed to identify a resident's elopement risk and did not update the care plan with interventions to prevent elopement. The resident, with severe cognitive impairment, was found wandering outside the facility. Staff members did not recognize this as an elopement, and the care plan was not updated promptly to include necessary interventions.
The facility failed to prevent elopement for two residents, one of whom was found by police hours later, and another who wandered outside unsupervised. The facility did not follow its care plan for hourly monitoring and failed to notify the legal representative or physician as per policy.
The facility failed to identify a severe 16% weight loss in a dialysis resident over two weeks due to discrepancies in weight recordings. The resident's pre-dialysis weights consistently decreased, but the facility's recorded weights were significantly higher, leading to a failure in recognizing the weight loss. Staff interviews and observations revealed issues with the weight monitoring process and malfunctioning scales.
The facility failed to continuously assess and document a resident's worsening penile ulcer. Despite recommendations for wound care and the facility's policy on perineal care, there were no nursing evaluations of the ulcer outside of the initial admission assessment. Staff interviews revealed that the resident's actions compromised wound care, but the facility did not document ongoing assessments or interventions.
A resident missed 15 days of prescribed medications, Flomax and Finasteride, intended to improve urine flow and assist in catheter removal. The error occurred due to incorrect physician orders, causing the resident anxiety about the upcoming catheter removal.
The facility staff failed to use standard precautions while handling soiled laundry, lacking protective gowns and gloves, which could lead to cross-contamination. This practice violated the facility's policy and CDC guidelines, as confirmed by staff interviews and observations.
A resident arrived at a follow-up appointment soiled with urine and dried stool, leading to feelings of embarrassment and humiliation. The resident reported not being toileted or changed all day, and her medical records showed 37 instances of incontinence within a month. Despite this, facility staff denied the resident was soiled prior to the appointment, and a grievance filed by the family member was dismissed as an accident.
A resident with a history of left-sided weakness from a stroke experienced an unwitnessed fall resulting in a fractured hip. The facility failed to conduct a root cause analysis to determine the cause of the fall or implement preventive measures, despite their policy requiring such actions.
The facility failed to complete an accurate MDS assessment for a resident with bowel and bladder incontinence. Despite the resident and medical records indicating incontinence, the MDS assessment inaccurately reported continence, leading to a deficiency in providing appropriate care.
The facility failed to implement a baseline care plan within 48 hours for a new resident who required assistance with dressing, toileting, and bathing. The care plan was not completed until 14 days after admission and lacked essential information. Staff members provided inconsistent information about the resident's condition and care needs, and one staff member was unaware of how to access the care plan.
The facility failed to complete a comprehensive, person-centered care plan for a resident with a knee fracture, resulting in inconsistent care and unmet needs related to ADLs, bowel and bladder status, and physical therapy services.
Failure to Prevent and Manage Pressure Ulcer Progression
Penalty
Summary
A resident who was admitted with intact skin on the sacrum developed a Stage III pressure ulcer that progressed to a Stage IV, with healing ultimately not achievable. The resident was dependent on staff for all care needs and had a history of medical co-morbidities, increasing the risk for pressure ulcers. Although interventions such as an air mattress, repositioning, use of a wedge, and a cushion in the wheelchair were implemented, documentation showed that repositioning every two hours was not consistently performed or recorded. The care plan specified limited time in a wheelchair and frequent repositioning, but these interventions were not reliably documented or executed. Wound care documentation was inconsistent, with measurements and identification of undermining and tunneling not reliably recorded. Dressing changes ordered by the physician were missed on multiple occasions, as evidenced by gaps in the treatment administration records. The wound was identified as infected at one point, and the resident received several courses of antibiotics for wound infection and cellulitis. However, the care plan did not specify the location or severity of the wound, and interventions for pain management prior to wound treatments were not consistently documented, despite the resident refusing some treatments due to pain. Staff interviews indicated that the resident occasionally refused repositioning, but staff generally believed the resident did not frequently refuse care. There was a lack of consistent documentation regarding refusals and pain management interventions. The combination of missed repositioning, incomplete wound care documentation, missed dressing changes, and insufficient pain management contributed to the failure to prevent the development and worsening of the pressure ulcer.
Failure to Properly Store, Label, Date, and Monitor Food Items and Temperatures
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen regarding the storage, labeling, dating, and discarding of food items. Specifically, in the backroom cooler, several food items were found either past their use by date, not labeled, not dated, or not properly covered. Examples included tortillas with an expired use by date, a potato-like item wrapped in foil without a label or date, beef and mushrooms in pans or bags without labels or dates, uncovered and unlabeled hotdogs, ground beef, deli ham, sausages with only a date, and chicken with two different dates. Staff confirmed that the use by date should be seven days after opening, and facility policy requires proper labeling, dating, and timely use or disposal of refrigerated foods. Additionally, the refrigerator next to the juice dispenser lacked a temperature log, and there was no evidence of temperature monitoring for that unit. Staff confirmed that all refrigerator units should have their temperatures monitored. Facility policy also mandates daily and routine monitoring of food temperatures and refrigeration equipment to ensure safe storage. These failures may affect any resident consuming food from these storage areas.
Failure to Control Persistent Urine Odors in Resident Hallway
Penalty
Summary
The facility failed to maintain a homelike environment and adequately control persistent urine odors in the 400B hallway, affecting two of 39 sampled residents and their visitors. Multiple observations over several days documented a strong, unpleasant urine smell throughout the hallway. Interviews revealed that one resident, who previously maintained a clean home before a dementia diagnosis, would not have tolerated such conditions, and her family expressed concern about the overwhelming odor upon her relocation to the hallway. The family also noted that excessive use of odor-masking spray caused the resident to cough, and they attempted to mitigate the smell with personal air fresheners and a fan. Another resident also commented on the persistent malodor in the area.
Infection Control Failures in Blood Draws, Precautions, and Kitchen Hygiene
Penalty
Summary
Contracted staff failed to follow safe and effective blood-draw practices by attempting to draw a resident's blood in the main dining room while the resident was eating breakfast and another resident was present at the table. The contracted staff stated they had been told by a facility staff member that they could draw blood in the dining room if the resident consented, and they confirmed they had not received any additional training on the facility's infection control expectations. Facility staff interviews revealed that contracted staff were expected to follow the facility's guidelines and not perform blood draws in common areas, but no additional training or clear communication of these expectations had been provided to the contracted staff. The facility did not implement appropriate transmission-based precautions (TBP) for residents on droplet and contact precautions. For a resident on droplet precautions due to parainfluenza virus pneumonia, there was no signage on the outside of the door, and personal protective equipment (PPE) was stored inside the room rather than outside, contrary to facility policy. Staff interviews confirmed that signage and PPE placement did not meet policy requirements, and documentation showed the resident was on droplet precautions at the time of the observation. For another resident on contact precautions due to a methicillin-susceptible Staphylococcus aureus (MSSA) infection, PPE was inconsistently placed, and staff were observed entering the room without donning PPE, despite policy requiring PPE to be donned before room entry. In the kitchen, staff failed to follow proper hand hygiene and glove use protocols. One staff member was observed sweeping the floor with gloved hands and then handling food items without changing gloves. Another staff member handled both soiled items and ready-to-eat food with the same pair of gloves, without changing gloves or washing hands between tasks. Facility policy required gloves to be changed between tasks and for staff to adhere to hygienic practices to prevent food contamination, but these procedures were not followed during the observations.
Failure to Provide Resident with Properly Fitting and Sufficient Clothing
Penalty
Summary
A resident who was cognitively intact and valued choosing her own clothing was not provided with adequate or properly fitting clothes during her stay. Despite having personal clothing available at her previous assisted living facility, staff did not make efforts to retrieve these items or ensure she had enough suitable clothing. Observations over several days showed the resident repeatedly wearing the same ill-fitting shirt, and her closet was found to be empty except for a few items, none of which fit appropriately. The resident expressed distress about her lack of appropriate clothing, becoming tearful when discussing the issue. Interviews with staff revealed that while spare clothing was available in a linen closet, it was often used for residents admitted from hospitals, and there was an expectation that social services would contact families for additional clothing when needed. However, no staff had requested the resident's clothing from her previous residence, and the clothing provided by the facility did not fit. Facility policy required residents to be groomed and dressed according to their preferences, but this was not followed in the resident's case, impacting her dignity and emotional well-being.
Failure to Arrange Timely Vision Services for Resident
Penalty
Summary
A deficiency occurred when the facility failed to ensure a resident received proper treatment, services, and assistive devices to maintain optimal visual abilities. The resident repeatedly reported difficulty seeing, even with the glasses provided, and expressed frustration over not being able to see the eye doctor despite multiple requests. Observations confirmed the resident's ongoing struggle to watch television and read, and interviews with staff revealed that no eye appointment had been scheduled, even though the need was documented in progress notes and communicated among staff. The resident's only available glasses were simple readers brought in by a family member, and his magnifying glass was broken and awaiting replacement by his sister. Documentation showed that a referral for an eye exam was made by the provider, and staff were aware of the resident's visual difficulties, but there was no evidence that an appointment was scheduled or transportation arranged. The facility's policy required staff to refer identified needs for vision services to social services, who were then responsible for making appointments and arranging transportation. Despite these requirements and ongoing monitoring, the resident did not receive timely access to necessary vision services.
Failure to Assess and Support Self-Catheterization for Resident with Indwelling Catheter
Penalty
Summary
A deficiency occurred when the facility failed to address the discontinuation of an indwelling urinary catheter for a resident who was admitted with the device. The resident, who is paraplegic and has a history of neurogenic bladder, previously managed his condition through intermittent self-catheterization and expressed a desire to return to this method for greater independence. Upon admission, the resident communicated his preference and history to staff, and a physician order was placed to assess his cognitive and physical ability to resume self-catheterization. However, no such assessment was completed, and the resident continued to have an indwelling catheter in place. Multiple staff interviews revealed a lack of awareness regarding the referral and physician order for the necessary cognitive and self-catheterization assessment. Documentation confirmed that no therapy evaluation or cognitive assessment was performed, and the order was not present on the facility's communication board. Staff also indicated that there was confusion about how to order self-catheterization supplies, and no supplies were procured for the resident. The facility's own policies require timely assessment for catheter removal and appropriate services to restore continence or independence, but these were not followed in this case. The resident did not receive the ordered evaluation to determine his ability to self-catheterize, nor was he provided with the supplies or services needed to restore his previous level of independence. The failure to complete the assessment and provide appropriate care was confirmed through record review, staff interviews, and observation, demonstrating noncompliance with facility policy and professional standards of practice.
Failure to Provide Behavioral Health Services for Resident with Depression
Penalty
Summary
A deficiency was identified when the facility failed to provide necessary behavioral health services to a resident who exhibited signs of depression following a significant life-changing event. The resident, a former school teacher who suffered a stroke resulting in right-sided weakness and the need for dialysis, expressed feelings of sadness, loss of independence, and uncertainty about recovery. During interviews and observations, the resident was noted to be tearful, reported not being approached about mental health services, and expressed interest in counseling, stating that it could help him mentally. Staff interviews confirmed awareness of the resident's depressive symptoms, with one staff member acknowledging that the resident seemed depressed and would likely benefit from mental health counseling. Despite this, there was no documentation of any follow-up or referral for behavioral health services, and the resident's participation in activities was minimal. The staff member who completed the PHQ-9 assessment upon admission recalled discussing mental health therapy with the resident but admitted there was no documentation of this conversation. Review of the resident's records showed a PHQ-9 score indicating moderate depression at admission, with no subsequent assessments completed before the survey. The care plan identified mood problems and included general interventions such as encouraging meaningful activities and monitoring mood, but there were no specific interventions or referrals for behavioral health services documented. The facility's policy requires person-centered behavioral health care, but the lack of documented interventions or referrals for the resident's depressive symptoms constituted a failure to provide necessary behavioral health services.
Failure to Identify and Address Elopement Risk
Penalty
Summary
The facility failed to identify a resident's risk of elopement and did not update the care plan with necessary interventions to prevent such incidents. The resident, who had a severe cognitive impairment as indicated by a BIMs score of 3, was found wandering outside the facility. Despite this incident, staff members did not recognize it as an elopement. Staff member A observed the resident near the doors but did not consider the resident's actions as an elopement. Staff members B and D were unaware of the resident's tendency to sit near the doors or go outside alone, while staff member C, who was familiar with the resident's habits, was informed of the wandering incident after it occurred. The care plan for the resident was not updated in a timely manner following the elopement incident. It was only on a later date that interventions were added to the care plan to prevent further elopements. This delay in updating the care plan highlights a lapse in the facility's response to the resident's elopement risk, as the necessary interventions were not promptly implemented to ensure the resident's safety.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to identify and manage the elopement risk for two residents, leading to incidents where both residents left the facility unsupervised. One resident, identified as having a high elopement risk, was able to leave the facility and was found by the police several hours later, a significant distance away. The facility did not adhere to its care plan, which required hourly monitoring and checking the functionality of the resident's wander guard bracelet. The incident report indicated a lapse in monitoring, as the resident was last seen at 3:00 a.m. and was not found in their room at 4:15 a.m., with the elopement being reported to authorities at 5:00 a.m. Another resident, who had severe cognitive impairment, was found wandering outside the facility. The nursing notes did not document the notification of the resident's legal representative or attending physician, nor was the resident reassessed upon return, as required by the facility's elopement policy. Staff interviews revealed inconsistencies in awareness and monitoring of the resident's behavior, with some staff unaware of the resident's tendency to sit near exit doors. The resident's care plan was not updated with interventions to prevent further elopement until after the incident.
Failure to Identify Severe Weight Loss in Dialysis Resident
Penalty
Summary
The facility failed to identify a significant discrepancy in weight recordings for a dialysis resident, leading to a severe 16% weight loss over two weeks. The resident's Dialysis Communication Records showed a consistent downward trend in weight, with no body or fluid weight gain between treatments. Despite this, the facility's weekly weight summary showed conflicting weights, which were used in the IDT weight meeting and failed to identify the resident's weight loss. The resident's pre-dialysis weights consistently decreased, but the facility's recorded weights were significantly higher than those recorded at dialysis, leading to a failure in recognizing the severe weight loss. Interviews with staff revealed that the weight monitoring process relied on the electronic health record dashboard and nursing concerns. Staff member M noticed the weight loss only after observing muscle and fat loss in the resident. Additionally, an observation of the weighing process showed that the mechanical lift scale was not functioning correctly, as it displayed an incorrect weight. Staff member A mentioned that maintenance had a schedule for calibrating the scales, but this did not prevent the discrepancy in the resident's weight recordings.
Failure to Continuously Assess and Document Worsening Penile Ulcer
Penalty
Summary
The facility failed to continuously assess and document the condition of a resident's penile ulcer, which was progressively worsening. The resident was admitted with skin concerns to the groin, including moisture and excoriation to the head of the penis. Despite the hospital discharge summary recommending wound care and noting the progression to a penile ulcer, the facility's records showed no nursing evaluations of the ulcer outside of the initial admission assessment. The facility's policy on perineal care required noting and reporting any skin changes, but this was not followed, as there was no documentation on the resident's penile ulcer or its worsening status in the nursing progress notes from the time of admission to the date of the surveyor's request for records. The care plan initiated later also failed to address the worsening condition adequately. Interviews with staff revealed that the resident's wound care was being compromised by the resident's actions, such as wiping off the applied wound care and touching himself, which made the wound care difficult. Despite these challenges, the facility did not document ongoing assessments or interventions to address the worsening ulcer, leading to a deficiency in providing appropriate treatment and care according to orders, resident’s preferences, and goals.
Medication Error Omission for Resident
Penalty
Summary
The facility failed to ensure a resident was free from a medication error omission, resulting in the resident missing 15 days of two prescribed medications, Flomax and Finasteride. These medications were intended to improve urine flow and assist in the resident's catheter removal. The resident had a urinary catheter placed due to urinary retention while in the hospital, and the plan was to continue these medications before a follow-up with urology. However, the resident's Medication Administration Record (MAR) showed that Finasteride was not administered, and Flomax was discontinued. The resident expressed anxiety about the upcoming catheter removal, and a staff member confirmed that the physician orders were not correctly followed, leading to the medication error.
Failure to Use Standard Precautions in Laundry Handling
Penalty
Summary
The facility staff failed to use standard precautions while handling soiled laundry, which could lead to cross-contamination. During an observation, it was noted that there were no protective gowns or gloves available for staff in the dirty linen area of the laundry room. A staff member confirmed that they did not use any personal protective equipment (PPE) while handling soiled laundry, simply throwing it into the washing machine without any covers or gloves. This practice was in direct violation of the facility's policy on handling soiled linen, which mandates the use of gloves and other protective equipment as necessary. Additionally, the facility's policy explicitly states that all used linen should be treated as potentially contaminated and should not come into contact with uniforms or the floor. The lack of adherence to these guidelines was further highlighted when another staff member inquired about the need to educate laundry staff on the proper use of PPE. The facility's failure to provide and enforce the use of appropriate PPE for laundry staff was also inconsistent with best practices outlined by the Centers for Disease Control and Prevention (CDC), which recommend the use of tear-resistant gloves, gowns, aprons, and face protection when handling soiled linens.
Failure to Provide Dignity and Respect to Resident
Penalty
Summary
The facility failed to provide dignity and respect to a resident, leading to feelings of embarrassment and humiliation. During a follow-up appointment at a local physician's office, the resident arrived soiled with urine and dried stool. The resident's incontinent brief was saturated and had leaked onto her clothing and wheelchair. The resident reported not being toileted or changed all day, which was corroborated by the nurse who assisted her at the appointment. The resident and her family member both expressed feelings of embarrassment and humiliation due to the incident. Upon returning to the facility, the resident's room had a strong urine smell, and she confirmed occasional bowel and bladder incontinence, requiring assistance with toileting. The resident had been living independently before her admission and had recently started to regain some independence. Despite this, the facility staff denied that the resident was soiled prior to her appointment. A grievance was filed by the family member, but the facility's investigation concluded that the resident was continent and the incident was an accident. However, the resident's medical records showed 37 instances of incontinence within a month, contradicting the staff's claims.
Failure to Conduct Root Cause Analysis for Resident Fall
Penalty
Summary
The facility failed to complete a thorough investigation, including a root cause analysis, for a fall with injury involving a resident. The resident, who had a history of left-sided weakness from a stroke, experienced an unwitnessed fall in his room, resulting in a fractured hip. Despite the resident being sent to the emergency room and undergoing surgery, staff members were unable to determine the cause of the fall or articulate any root cause analysis during interviews. The facility's policy mandates conducting root cause analysis to prevent recurrences and improve resident care, but this was not followed in this case. The incident report submitted to the State Survey Agency indicated that an investigation was started, but the findings did not include a root cause analysis. Staff interviews revealed that the resident might have fallen while attempting to walk to the bathroom, but no formal analysis was conducted to confirm this or to implement preventive measures. The facility's failure to conduct a root cause analysis and implement corrective actions as per their policy represents a significant deficiency in their management of resident care and safety.
Inaccurate MDS Assessment for Bowel and Bladder Incontinence
Penalty
Summary
The facility failed to complete an accurate MDS assessment for a resident in the area of bowel and bladder incontinence. During an observation and interview, the resident reported issues with bowel and bladder incontinence, which had worsened after knee surgery. Despite this, the resident's MDS assessment indicated that the resident was always continent of bowel and bladder. Interviews with staff members revealed inconsistencies in their knowledge of the resident's continence status, with some staff members stating the resident was continent and others being unfamiliar with the resident's condition. A review of the resident's electronic medical record showed 37 instances of incontinence over a one-month period, contradicting the MDS assessment. The case manager responsible for MDS assessments stated that the facility did not have a specific MDS policy and relied on the guidelines set forth in the RAI manual. The case manager also mentioned that another MDS nurse had completed the resident's MDS assessment while she was out of town. The facility's policy on incontinence indicated that residents who are incontinent should receive appropriate treatment and services to prevent infections and restore continence. However, the inaccurate MDS assessment failed to reflect the resident's actual condition, leading to a deficiency in providing appropriate care and services.
Failure to Implement Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to implement a baseline care plan within 48 hours of admission for a new resident, which is a requirement according to their policy. The resident, who had a knee brace and was non-weight bearing on her left leg upon admission, required assistance with dressing, toileting, and bathing. However, the baseline care plan was not completed and locked until 14 days after admission, and it did not address the resident's transfer status, weight-bearing status, or activities of daily living. During interviews, staff members provided inconsistent information about the resident's condition and care needs. One staff member stated the resident was continent of bowel and bladder, while another mentioned the resident had problems with incontinence. Additionally, a staff member who did not usually work on the unit was unaware of how to access the resident's care plan and relied on verbal reports for information. This lack of a timely and comprehensive care plan had the potential to affect the quality of care for all new admissions in the facility.
Incomplete Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to complete a comprehensive, person-centered care plan for a resident who had a knee fracture and was admitted to the facility non-weight bearing. The resident required assistance with activities of daily living (ADLs) such as dressing, toileting, and bathing. Despite the resident's progress in becoming more independent and being able to bear weight with a knee brace, the care plan did not include focus, goals, or interventions related to ADLs, bowel and bladder status, transfer status, weight-bearing status, or physical therapy services. This omission was observed during interviews and record reviews, where staff members provided inconsistent information about the resident's needs and care plan details. During observations and interviews, it was noted that the resident's room had a strong urine smell, and the resident reported occasional bowel and bladder incontinence. Staff members had varying levels of knowledge about the resident's condition and care needs, with some unable to access or verbalize the care plan. The facility's document on comprehensive care plans indicated that care plans should include measurable objectives and timeframes to meet the resident's needs, but this was not reflected in the resident's electronic care plan dated February 2024.
Latest citations in Montana
A resident with a history of hematuria, renal failure, anemia, and recent blood transfusions was readmitted from the hospital with discharge instructions to pause apixaban, but the facility failed to obtain admission orders and did not clarify the incomplete anticoagulant order. The resident’s care plan did not address anticoagulant use or monitoring, and staff administered multiple doses of apixaban after readmission. Nursing notes documented blood in the nephrostomy drainage bag on two days without provider notification or intervention, followed by worsening weakness, poor intake, and hypoxia that led to hospital transfer. Hospital records showed the resident had gross hematuria, hypotension, respiratory distress, acute kidney injury, and a critically low Hgb requiring transfusion, and a late entry note acknowledged that the discharge order to hold apixaban had been overlooked.
A resident who was cognitively intact but dependent for bowel and bladder care and limited in ROM reported that a specific staff member repeatedly left call lights unanswered for extended periods, causing the resident to soil briefs and then be pressured to ambulate to the bathroom and sign refusal-of-care forms. A family member corroborated long call-light waits and rude interactions, and staff noted the resident became anxious and displayed behaviors when care was forgotten or incomplete. Despite verbal reports, emails, and documentation at a care conference describing long call-light waits, incontinence episodes, and refusal forms used at night, no grievance was filed and the alleged neglect was not reported or investigated. The resident also developed unaddressed skin issues on the heels, coccyx, and ears, and +2 pitting edema in both feet and ankles, with offloading devices found unused in the room and no related wound orders or documented weekly skin assessments.
Multiple residents experienced inadequate pressure ulcer and skin care when staff failed to perform timely and accurate skin assessments, obtain and follow wound care orders, and implement appropriate care plan and nutritional interventions. One resident admitted with multiple skin issues developed a large, foul-smelling coccyx ulcer that was not promptly evaluated, lacked early wound orders, and was not reflected in the care plan or consistently documented on the TAR. Another resident with a coccyx pressure injury and a spinal incision had delayed wound measurements, late dietitian notification, missed daily wound treatments, and late addition of protein supplementation to the care plan. A resident using oxygen had painful, reddened ears and heel/eschar issues that were not captured in admission documentation, lacked wound orders, and had no subsequent skin assessments recorded. A further resident with a coccyx pressure ulcer had conflicting MDS staging and "present on admission" coding, along with numerous days where ordered daily wound care was undocumented or absent. Staff interviews revealed inconsistent weekly skin checks, missed admission skin evaluations due to EHR changes, limited dietitian availability, and wound care being performed by staff without formal wound training, all contrary to the facility’s own skin integrity policy.
The facility failed to thoroughly investigate, monitor, and document multiple abuse allegations involving staff-to-resident and resident-to-resident incidents. In one case, a resident reported that a staff member blew marijuana vape smoke in his face, but there was no related nursing documentation or post-incident monitoring. In another case, a resident reported being hit by another resident, was found with a red mark on the head, and was sent to the ER, yet nursing notes for both residents lacked documentation of the incident and follow-up monitoring. In a third case, a cognitively impaired resident with developmental delay was found in another resident’s room while that resident’s hands were being removed from inside the resident’s pants and shirt, after which the resident complained of pain and was sent to the ER; again, nursing notes for both residents contained no documentation of the event or post-incident monitoring, and the investigator did not fully interview or obtain written statements from all involved as required by facility policy.
The facility failed to thoroughly investigate multiple allegations of abuse and neglect, including one resident’s report that a staff member was verbally demeaning and rushed her during oral care, and another resident’s report of inadequate ADL care with prolonged call light response times and being left in a soiled brief. A staff member admitted not reporting or investigating the latter allegation, and no related documentation was produced. In a separate incident, a resident alleged a CNA turned off the call light and refused requested personal care; the facility interviewed only the involved staff and did not interview other residents who might also have experienced call lights being turned off without care being provided, despite a witness stating this was a common practice by multiple staff. Additional requested interviews and information were not provided to surveyors.
Surveyors found that the facility failed to complete timely and comprehensive baseline care plans for three newly admitted residents. One resident with multiple serious conditions and a coccyx wound had no baseline care plan addressing wound care, pain, or chronic conditions for several days after admission. Another resident with dysphagia, dementia, and documented skin issues on the buttocks, heels, and knee had a baseline care plan that did not identify pressure wounds or related treatments. A third post‑surgical resident with a Stage 3 pressure ulcer and a lumbar incision had a baseline care plan that omitted wound management and post‑operative pain control. A staff member reported that baseline care plans are only generated after the admission nursing assessment is completed and locked, and acknowledged they are not always completed on time.
A resident’s long-time friend, a former employee previously terminated over an abuse allegation, was barred from entering the facility when she attempted to visit, and was told law enforcement would be called if she returned. Another individual confirmed awareness of the restriction, expressed no concern about the friend abusing the resident, and stated that the facility did not offer supervised or common-area visits. A staff member reported that any former employee terminated for an abuse allegation was categorically prohibited from returning to the building, without considering the resident’s relationship with the visitor, despite a visitation policy stating residents have the right to receive visitors of their choice and allowing only limited or supervised access when abuse is suspected or found.
The facility failed to follow its grievance policy by not documenting or investigating a grievance request from a resident and family member alleging that a CNA ignored call lights for extended periods, failed to provide timely ADL care, forced ambulation to the bathroom at night, and pressured the resident to sign refusal-of-care forms, causing the resident to feel afraid and neglected. In a separate case, the facility did not adequately investigate or document a grievance from a dependent, mobility-impaired resident who reported that a male CNA was rough and refused to reposition his contracted legs for comfort, and the staff member assigned to the investigation did not identify the CNA involved or record her explanation of the situation on the grievance form.
A resident reported that a former staff member repeatedly left the call light unanswered for extended periods, did not provide needed ADL assistance, and encouraged the resident to sign refusal-of-care forms, resulting in the resident soiling briefs before being asked to ambulate to the restroom. Another staff member stated that no care concerns had been brought to their attention and acknowledged that the alleged abuse and neglect were not reported. When surveyors requested IDT notes, root cause analysis, reporting, and investigation documents related to the staff member and this resident, the facility was unable to provide any documentation, indicating the allegation was not timely reported to the State Survey Agency or investigated.
Surveyors found that several residents did not receive appropriate ADL and hygiene assistance or accurate documentation of those services. A dependent resident reported inconsistent help with meals, only sponge baths instead of showers for several weeks, lack of shaving, and prior grievances about staff not assisting with a urinal or repositioning his legs. Another cognitively intact resident, dependent for oral care and dressing, stated he was not offered mouthwash or a warm washcloth, and staff confirmed they had never offered mouthwash despite charting that personal hygiene was provided. A third resident, largely independent with self-care, reported that washcloths were not available unless requested, and no washcloths were seen in the room, while documentation showed staff performing most of her personal hygiene. These findings showed failures to offer basic hygiene items and to accurately document ADL care provided.
Failure to Clarify Anticoagulant Orders Leads to Unnecessary Drug Administration and Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s drug regimen was free from unnecessary drugs when nursing staff did not clarify and correctly implement anticoagulant orders upon the resident’s readmission. The resident had been hospitalized for hematuria, renal failure, and anemia, received multiple blood transfusions, and was discharged back to the facility with an After Visit Summary instructing that apixaban (an anticoagulant) be paused, with no restart date specified. Despite this, the facility’s admission documentation for the readmission date showed no admission orders, and the apixaban order was not clarified with the physician. The medication was restarted and administered after readmission, even though the hospital documentation indicated it was to be paused and later discontinued. Following readmission, the resident’s Medication Administration Record showed that seven doses of apixaban were given. The resident’s care plan, initiated on the readmission date, did not identify any problems, goals, or interventions related to anticoagulant use, safety, or monitoring for side effects. Nursing progress notes documented that the resident had a right-sided nephrostomy with yellow urine drainage on the day of readmission, and then documented blood in the nephrostomy drainage bag on two consecutive days. However, there was no documentation that the provider was notified about the hematuria or that any action was taken in response to this change. Subsequently, nursing notes described the resident as weak, not eating, unable to maintain a sitting position, and having low oxygen saturation that did not adequately improve with increased supplemental oxygen, leading to transfer to the emergency department. Hospital records from that visit showed the resident presented with hypoxia, hypotension, profound weakness, respiratory distress, gross hematuria, acute kidney injury, and a critically low hemoglobin of 6.9 g/dL, and that the resident had received an anticoagulant and required blood transfusions. A late entry nursing note at the facility later documented that the hospital discharge summary had been overlooked, the order to hold apixaban was not implemented, and the resident continued to receive apixaban until readmission to the hospital. The facility’s root cause analysis attributed the event to ambiguity in discharge communication and medication reconciliation workflow and noted that the apixaban order was incomplete and not clarified before administration.
Failure to Identify and Address Neglect, Call-Light Delays, and Skin Concerns
Penalty
Summary
The deficiency involves the facility’s failure to identify, report, and address neglect of care concerns for a cognitively intact resident who was dependent on staff for bowel and bladder care and had range of motion limitations in both upper and lower extremities. The resident reported that a specific staff member (NF7) repeatedly left his call light on for extended periods, often over 45 minutes and up to hours at night, resulting in him soiling his brief with bowel and bladder incontinence while waiting for assistance. When staff eventually responded, NF7 would attempt to have the resident ambulate to the restroom despite the resident already being incontinent, and would then encourage him to sign refusal of care forms when he declined. The resident described being upset, anxious, and irritable, and stated he usually “peed” and “soiled” his pants and developed skin issues from sitting so long without being cleaned. A family member (NF6) corroborated concerns about long call light response times, stating the resident’s call light was left on for over an hour, leading to incontinence episodes, and that NF7 spoke to the resident in a rude and angry manner. NF6 reported these concerns in person, by phone, and by email to facility staff, including staff members A and C. Staff member O reported that the resident had anxiety and behaviors that were exacerbated when staff forgot about him or failed to perform all required care. Despite these reports and the resident’s expressed fear and anxiety when NF7 was working, no staff member asked the resident if he felt safe or explored what had occurred on nights with or without NF7, and the alleged neglect was not reported or investigated by facility leadership. The resident also had unaddressed skin concerns and edema that were not properly identified or managed. Staff member B stated weekly skin assessments should have been done but that wound care staff were unaware of any ear or coccyx issues, and the physician orders lacked wound orders for the resident’s left heel. On assessment, staff member P observed eschar on the left heel that appeared to need debridement, redness and cracking on the right heel, pink coccyx, and reddened ears, with delayed capillary refill on one ear, as well as +2 pitting edema in both feet and ankles that had developed during the resident’s stay. Posey boots intended to offload the heels were found in the resident’s cabinet, and staff member P stated she had never seen them used on the resident. Additionally, at a care conference documented and signed by staff member C, the resident reported waiting 20–40 minutes for call lights at night, having accidents while waiting, and being made to sign refusal papers when he declined to go to the bathroom after already being wet. Despite this documentation of neglect-related concerns, no grievance was filed, and staff members B and C stated they were unaware of or did not report or investigate any alleged abuse or neglect for this resident.
Failure to Assess, Document, and Treat Pressure Ulcers and Related Skin Conditions
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain an effective system for pressure ulcer prevention, identification, assessment, and treatment for multiple residents. For one resident admitted with existing skin issues on the buttocks, both heels, and a right knee wound, nursing notes documented a silicone foam dressing on the coccyx that was saturated with foul-smelling brown-yellow drainage, and a non-stageable pressure ulcer with slough, black eschar, and a large reddened border. This was the first detailed description of the coccyx pressure ulcer, and there were no wound care orders in the chart at that time. A subsequent weekly skin evaluation described a large, deep coccyx wound with copious foul-smelling drainage and extensive slough and granulation tissue, but incorrectly listed that date as the first observation despite the wound being identified nine days earlier. Wounds on the left heel, right outer ankle, and right knee were not evaluated until several days after admission, and the right heel was never evaluated during the stay. The resident’s care plan did not identify pressure ulcers as a problem and contained no interventions for pressure ulcer care or nutrition to support wound healing, and the treatment administration record showed wound treatments were not ordered until several days after admission and were then not consistently documented as completed. Another resident was admitted with a coccyx area that was open and possibly caused by pressure, and a late entry note identified a Stage 3 pressure ulcer to the coccyx from admission. However, the nutrition evaluation form later indicated “no” to the presence of a pressure injury and instead listed “other skin condition,” even though coccyx wound care was ordered. The weekly skin evaluation documented the first observation and measurements of the coccyx wound two weeks after admission, and the dietitian was not notified until several days after that. The treatment record showed that daily wound care orders for both the coccyx pressure ulcer and a surgical spine incision were not carried out on at least two days. Nutritional interventions to support wound healing, including a protein supplement, were not added to the care plan until more than two weeks after the wound was identified. Staff interviews revealed that the dietitian was only present in the facility limited hours on two days per week, that residents admitted later in the week might not be assessed nutritionally until the following week, and that a fourteen-day delay in nutritional assessment, while allowed, was acknowledged as not best practice for residents with wounds. A third resident using oxygen reported pain behind both ears, and observation showed that oxygen tubing protectors had slid out of place, leaving the ears unprotected. The right ear was red where the tubing rested, and the left ear was very red with a whitish substance in the crease. Staff later described this resident’s skin as having eschar on the left heel that appeared to need debridement, a red and cracked right heel, a pink coccyx, and reddened ears, with the left ear showing slower capillary refill. The facility’s records contained no wound orders for the left heel, no skin assessments since the most recent readmission, and an admission nursing evaluation that documented the skin as warm, dry, intact, and without wounds. A fourth resident had a coccyx pressure ulcer that was present on admission and gradually decreasing in size according to wound assessments. However, MDS assessments contained inconsistent documentation: one assessment showed no unhealed pressure ulcers on admission, a later discharge assessment documented a Stage IV pressure ulcer present on admission, and a subsequent quarterly assessment documented a Stage III pressure ulcer not present on admission. Treatment administration records showed no coccyx wound treatment in one month, initiation of daily wound care late in the following month with at least one missed documented treatment, and in the next month, daily wound care orders with more than half of the scheduled treatments lacking documentation of completion. In the subsequent month, the TAR failed to show any wound care performed for the coccyx pressure ulcer. Staff interviews indicated that weekly skin checks were the facility practice but were not consistently completed, that nurses were not always coding or documenting wounds correctly, and that admission skin evaluations were sometimes not done due to issues with a new computer system. A staff member performing wound care on one resident’s coccyx reported having no formal wound training and described a wound bed fully covered with thick yellow-tan slough, which, according to the cited National Pressure Ulcer Advisory Panel guideline, could not be accurately staged, despite the facility’s practice of staging it as a Stage III pressure ulcer. The facility’s own Skin Integrity policy required that upon admission, the licensed nurse establish a plan of care based on risk factors or presence of wounds, conduct ongoing weekly full-body skin audits, document new skin impairments with detailed characteristics and measurements, record qualifying wounds on the weekly skin evaluation form, notify the medical provider and obtain treatment orders, notify the resident or representative, notify the registered dietitian, and implement and document appropriate care plan interventions. The findings across these residents showed that these policy steps were not consistently followed: admission and weekly skin evaluations were missed or delayed, wounds were not accurately or timely documented or staged, treatment orders were delayed or not consistently carried out, nutrition and care plan interventions for wound healing and prevention were not promptly implemented, and staff responsible for wound care sometimes lacked formal wound training.
Failure to Thoroughly Investigate and Document Multiple Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to complete thorough investigations, monitoring, and documentation for multiple abuse allegations. In one incident, a resident reported that a staff member blew marijuana vape smoke in his face. The staff member later admitted to vaping marijuana in the resident’s room. Despite this, the resident’s nursing progress notes for the period following the incident contained no documentation of the event or any post-incident monitoring, and the psychosocial impact assessment tool indicated that no ALERT charting had been done by nursing or social services. In a second incident, a resident sitting in a wheelchair by the nurse’s station told a staff member that another resident had hit him; assessment revealed a red mark on the resident’s head, and the resident was sent to the emergency room at the family’s request. However, nursing progress notes for both the alleged victim and the alleged aggressor for the days following the incident contained no documentation of the incident or any post-incident monitoring. The staff member responsible for the investigation stated that he relied on video footage and interviews with the two residents, but these interviews were only documented in the incident report, and no other staff or residents on shift were interviewed. In a third incident, staff found one resident in another resident’s room and observed the second resident removing his hands from inside the first resident’s pants and shirt; the first resident later stated, “It hurts down there,” and was sent to the emergency room. The first resident had diagnoses including unspecified symptoms involving cognitive functions and awareness, anxiety, depression, cerebral infarct, and was described as having a developmental delay with the mentality of an 8-year-old, while the second resident was cognitively intact based on a BIMS score of 14. Nursing progress notes for both residents for the days following the incident contained no documentation of the event or any post-incident monitoring. The staff member overseeing the investigation acknowledged that he did not document his post-incident checks, did not interview staff on shift or other residents, and no abuse education or protective measures for staff were documented, contrary to the facility’s abuse prevention policy that requires interviews with all involved, retrieval of written statements, and documentation of assessments and monitoring.
Failure to Thoroughly Investigate Allegations of Abuse and Neglect
Penalty
Summary
The deficiency involves the facility’s failure to fully investigate multiple allegations of abuse and neglect, including not identifying all potentially affected residents. One resident reported that a staff member (NF8) was “nasty and pushy” while assisting with oral care, telling her she should not take so long brushing her teeth because she only had eight teeth and making her hurry without giving her the time she needed. When the facility questioned NF8 about this incident, he resigned from his position. Review of the facility-reported incident showed no staff interviews were completed as part of the investigation, despite the importance of such interviews in understanding the incident and identifying root causes. Another resident reported inadequate ADL care by staff member NF7, including long call light response times and being left in a soiled brief for hours, and stated he had reported these concerns to facility staff. A staff member later stated they were unaware of any concerns from the resident or his family regarding NF7 and acknowledged they did not report or investigate the alleged abuse or neglect. When surveyors requested documentation such as interdisciplinary team notes, root cause analysis, reporting, and investigation related to concerns with NF7, none was provided. In a separate facility-reported incident, a resident alleged a CNA turned off the call light and refused to provide requested personal care. The facility interviewed only the staff involved that night and did not interview other residents who might have been affected by staff turning off call lights without providing care. A witness (NF5) reported that it was the facility’s usual practice to turn off call lights without providing help, that staff often told the resident they would return but did not always do so, and that multiple staff engaged in this behavior. Despite a request from surveyors, the facility did not provide additional resident interviews or information regarding this allegation by the end of the survey.
Failure to Complete Timely Baseline Care Plans for Wounds and Pain Management
Penalty
Summary
The deficiency involves the facility’s failure to complete timely and comprehensive baseline care plans that provided instructions for resident-centered care for three residents. One resident was admitted with multiple serious diagnoses, including acute kidney failure, anemia, atrial fibrillation, chronic respiratory failure, hypertension, a right femur fracture, morbid obesity, and muscle weakness. A nurse progress note documented a coccyx wound described as stage I open on the day of admission, yet no baseline care plan was initiated to direct staff in caring for the wound, managing pain, or addressing the resident’s chronic medical conditions. A care plan was not started until several days later, and when it was initiated, it only addressed advanced directives, oral/dental health problems, loneliness, and discharge planning, without including wound or pain management. Another resident was admitted with dysphagia, dementia, behaviors, a history of falls, and a urinary tract infection. Nursing progress notes documented skin issues on the buttocks, both heels, and the right knee, but the baseline care plan initiated the same day did not identify pressure wounds or any treatment for those wounds. A third resident, admitted after surgical repair of a lumbar 4 compression fracture, had a documented Stage 3 pressure ulcer and a lower back incision with intact staples on the admission nursing evaluation. However, the baseline care plan for this resident did not include wound management interventions or pain management for post-operative pain. During an interview, a staff member explained that the baseline care plan is triggered when the admitting nurse completes and locks the admission nursing assessment, and acknowledged that when assessments are not locked, baseline care plans are not completed and are not always done on time.
Failure to Honor Resident’s Right to Chosen Visitor
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to receive visitors of her choosing. A long-time friend of the resident, identified as NF1, reported that when she first attempted to visit the resident after the resident’s admission, staff member B escorted her out of the building and told her that law enforcement would be called if she returned. NF1 had previously been employed by the facility approximately four years earlier and had been terminated due to an allegation of abuse toward a resident. The facility did not allow her to visit the resident in any capacity. Another individual, NF2, stated he was aware that the facility was not allowing NF1 to visit the resident and that he knew about the prior abuse allegation but was not concerned about NF1 abusing the resident. NF2 stated he wanted NF1 to be allowed to visit and that the facility did not offer supervised visits or visits in a common area. He was hesitant to raise the visitation issue with the facility because he was concerned it might change how the resident was treated. Staff member B confirmed that any employee terminated due to an abuse allegation was not allowed to return to the building for any reason, and that this restriction was applied without considering the resident’s history with the visitor. The facility’s visitation policy stated residents have the right to receive visitors of their choice and that limitations may include denying or limiting access to individuals suspected of abuse until an investigation is completed or abuse is found, but the facility applied a blanket prohibition in this case.
Failure to Document and Investigate Resident Grievances Alleging Neglect and Inadequate Repositioning
Penalty
Summary
The deficiency involves the facility’s failure to follow its grievance policy and to ensure residents could voice grievances related to alleged abuse and neglect without discrimination or reprisal. One resident reported that a specific CNA (NF7) left his call light on for hours, did not assist with ADLs, and that this led to bowel and bladder incontinence while he waited for help at night. The resident stated that when the CNA finally responded, the CNA would force him to ambulate to the restroom instead of cleaning him in bed, and when the resident refused to ambulate, the CNA told him to sign a refusal of care form. The resident reported being afraid of this CNA and feeling neglected in his care, and he stated he reported these concerns to staff member C. An external email from NF6 to staff member C documented that the resident was afraid of NF7, described NF7’s statements about his job duties, and explicitly requested to file a grievance and have NF7 kept away from the resident. Additionally, a care conference note signed by staff member C documented the resident’s report of being made to sign refusal sheets at night and waiting 20–40 minutes for call lights to be answered. Despite this, staff member C, identified as the grievance official, stated there were no concerns brought forth from the resident or family regarding NF7, and no grievance was completed for this abuse/neglect allegation as required by the facility’s grievance policy. The deficiency also includes the facility’s failure to thoroughly investigate and document findings for another resident’s grievance regarding care. This resident, who had impaired mobility in both upper and lower extremities and was dependent for all ADLs except eating, reported that a night CNA was rough and refused to reposition his legs, and he stated he had complained to the facility but the issue continued. A written grievance from this resident documented that a male CNA would not readjust his legs for comfort. The grievance form’s investigative findings did not show any attempt to identify the specific night CNA involved or to clarify what care was being refused. Staff member E, who was responsible for investigating this grievance, could not recall details of the investigation and acknowledged she did not attempt to identify the accused CNA, characterizing the issue as a recurrent complaint and a miscommunication about repositioning due to the resident’s leg contractures. She stated she had encouraged the resident to be more specific about the repositioning requested but could not explain why this was not documented on the grievance form. The facility’s grievance policy required that grievances, including those involving abuse or neglect, be documented on a grievance form and investigated, but this was not done in accordance with policy for these residents’ complaints.
Failure to Timely Report Alleged Abuse and Neglect to State Agency
Penalty
Summary
The facility failed to timely report an allegation of abuse and neglect to the State Survey Agency involving one sampled resident, identified as resident #47. During an interview, resident #47 reported that a specific former staff member, NF7, would leave his call light on for hours, fail to assist with ADL care, and this lack of response resulted in the resident soiling his brief with bowel and bladder because he waited so long for help. The resident further stated that NF7 would encourage him to sign a refusal of care form and then expect him to ambulate to the restroom after he had already gone in his brief. In a separate interview, staff member B stated that no care concerns from the resident or family had been brought to their attention and acknowledged that they did not report the alleged abuse or neglect of care. A request by surveyors for documentation related to resident #47’s interdisciplinary team notes, any identified root causes, reporting, and investigation of concerns involving NF7 and resident #47 yielded no documentation by the end of the survey, demonstrating a lack of evidence that the allegation was reported or investigated as required.
Failure to Provide and Accurately Document ADL and Hygiene Assistance
Penalty
Summary
Surveyors identified that the facility failed to provide and accurately document assistance with activities of daily living (ADLs) for multiple residents. One resident, who was assessed on the MDS as dependent for all ADLs except eating (requiring only partial to moderate assistance with eating), reported not always receiving help with meals, having only sponge baths for several weeks instead of showers, and needing a shave while observed lying in bed in a hospital gown with several days of facial hair growth. This same resident had previously filed a grievance stating that a night nurse would not assist with use of a urinal despite his inability to do this himself, and that a male CNA would not readjust his legs for comfort. These findings showed a lack of consistent ADL assistance for a resident documented as dependent. Surveyors also found failures related to personal hygiene supplies and documentation for two other residents. One cognitively intact resident, dependent for oral hygiene and dressing, stated he had not been offered mouthwash or a warm washcloth to wash his face that day, and no mouthwash was present in his room; staff later confirmed they had never offered him mouthwash, despite documentation that personal hygiene was offered and that staff did most of the activity. Another resident, who stated she could wash her face, brush her teeth, and comb her hair mostly independently, reported that washcloths were never available unless she specifically asked staff, and on observation there were no washcloths in her room. Her EHR documentation showed staff did most of her personal hygiene activity, while staff later stated she was generally independent and that they had not been giving her a daily washcloth. These discrepancies demonstrated inaccurate ADL documentation and failure to routinely offer basic hygiene items such as washcloths and mouthwash.
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