Pioneer Care And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Dillon, Montana.
- Location
- 200 N Oregon St, Dillon, Montana 59725
- CMS Provider Number
- 275124
- Inspections on file
- 27
- Latest survey
- December 31, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Pioneer Care And Rehabilitation during CMS and state inspections, most recent first.
A resident with dementia repeatedly entered other residents' rooms, resulting in a physical altercation and ongoing aggressive behaviors, despite being on increased supervision and residing in a secured memory care unit. Staff documented multiple incidents of wandering, aggression, and mishandling of personal items, indicating that adequate supervision and necessary services were not consistently provided.
A resident with dementia and limited safety awareness, who was at risk for falls and receiving psychotropic medication, experienced multiple unwitnessed falls after an increase in Ativan dosage. The care plan included only minimal fall interventions, and the facility did not adequately assess or address the impact of the medication change, resulting in repeated falls and a fractured hip.
A resident with ongoing symptoms of headache, nausea, and bradycardia did not receive timely medical attention due to the medical director's lack of responsiveness to nursing staff requests. Staff reported difficulty reaching the medical director, who was rarely present and often did not return calls, resulting in delayed care and the resident requiring emergency room intervention.
The facility did not maintain an effective antibiotic stewardship program, failed to ensure timely medication delivery and drug regimen reviews, and lacked an updated QAPI plan. Staff had to obtain medications from a local store due to pharmacy issues, and no gradual dose reductions for psychotropic medications were completed. The infection preventionist role was unfilled by a certified individual, and the QAPI plan had not been reviewed or updated in over two years.
The facility did not have a qualified infection preventionist responsible for the infection prevention and control program. Documentation failed to identify a certified staff member in this role, and a staff member confirmed that the previous infection preventionist had left and the new hire was still in training.
Several residents had incomplete or improperly executed POLST forms, with missing required signatures, names, or dates, and in some cases, forms were left invalid according to state requirements. Staff interviews revealed delays and misunderstandings about the validity of unsigned forms. Additionally, a resident's code status was inconsistently documented across the POLST, physician orders, and daily nursing reports, with confusion regarding the authority of the resident's representative to make healthcare decisions.
The facility did not ensure that a licensed pharmacist consistently performed and documented monthly medication regimen reviews for residents on psychotropic medications. In one case, a resident's medication review omitted a prescribed drug and lacked documentation of the risks and rationale for continued use, while other residents' reviews were missing entirely due to issues with a previous pharmacy provider. Staff reported that inappropriate medication use contributed to a resident's fall and injury.
A resident received multiple overlapping antibiotics for UTIs and sinusitis over several months, with two antibiotics given simultaneously for the same infection and changes in therapy lacking documented rationale. The facility lacked infection tracking and an infection preventionist, and the resident developed C. difficile and persistent ESBL-positive UTIs during this period.
The facility did not report allegations of resident-to-resident abuse and two injuries of unknown origin, including a major injury, to the State Survey Agency as required. In one case, a resident had unexplained bruising and later sustained a fractured hip after an unwitnessed fall, with neither incident reported. In another case, two residents were involved in an alleged physical altercation, but the event was not reported after the facility determined it was not abuse.
A resident was discharged AMA without comprehensive discharge planning, proper documentation of education on risks, or provider notification. The care plan was updated only shortly before discharge, and required notifications and documentation were incomplete, contrary to facility policy.
A resident who was transferred to the hospital did not receive the required transfer discharge notice or bedhold documentation. Staff confirmed the absence of these documents and acknowledged ongoing problems with providing them, and record review showed no evidence of the required forms in the resident's file.
A resident was admitted without a completed baseline care plan within 48 hours, as required. The care plan lacked essential information such as code status, active diagnoses, and risks related to dementia, weakness, and psychotropic medication use. Signature sections for both the resident/representative and staff were left blank, and staff interviews revealed confusion about the care planning process and access to care information.
A resident with a history of needing adaptive utensils and a walled plate for eating did not consistently receive these items or adequate staff assistance during meals. Observations showed the resident struggling to feed herself, with meals left uneaten and difficulty using standard utensils and cups. Staff confirmed that adaptive equipment was not reordered after a recent hospitalization, and the care plan lacked specific interventions, resulting in unmet ADL needs.
A resident with recent hospitalizations and new need for eating assistance was left without help during meals, resulting in minimal food intake despite documentation showing otherwise. Over several months, the resident experienced severe weight loss, with repeated but unaddressed concerns about possible errors in weight measurements. The facility did not ensure accurate monitoring of nutritional intake or resolve discrepancies in weight documentation.
A resident with a recent history of respiratory issues experienced chest pain and worsening breathing difficulties over several days. Despite staff raising concerns and contacting the physician call center, there was a significant delay in obtaining new orders, and the resident's oxygen saturation continued to decline. The resident was ultimately transferred to the hospital for acute on chronic hypoxic respiratory failure.
A resident received more pain medication than prescribed due to inadequate monitoring, incomplete documentation, and inconsistent medication administration practices. Staff were not fully trained on facility-specific medication protocols, and the resident's pain management regimen was changed multiple times without proper oversight, resulting in adverse effects and hospitalization.
A resident experienced increased confusion after being found with two 50mcg Fentanyl patches applied, contrary to medication orders that specified using either one 50mcg patch or two 25mcg patches only if the 50mcg patches were unavailable. The error resulted from unclear communication of the conditional order, leading to improper administration.
Licensed staff repeatedly left medication carts unlocked and unattended in various areas, with pill packets exposed and drawers open. In one case, a staff member accessed the narcotics log book and controlled substance drawer from an unlocked cart and left them open while administering a controlled medication, only securing them after being prompted by a surveyor.
Staff did not perform hand hygiene during medication administration, including before and after giving an insulin injection. Two residents requiring enhanced barrier precautions for wounds did not have appropriate signage or supplies at their doors, and staff interviews revealed confusion about precaution protocols.
The facility did not ensure staff received adequate training on abuse identification and reporting, resulting in missed investigations and failure to report incidents involving two residents—one with unexplained bruising and another involved in a physical altercation. Documentation of abuse training was incomplete, and required reporting procedures were not consistently followed.
The facility failed to encourage residents to report concerns without fear of retaliation, leading to increased anxiety and depression among residents. The new administration, which began in December 2024, was associated with high staff turnover and unresolved issues, causing residents to isolate themselves and avoid activities. Staff noted negative interactions between the administrator and residents, contributing to the residents' dissatisfaction and fear.
A facility failed to provide consistent access to physician-ordered Methadone for a resident, resulting in multiple missed doses. The resident, who was transitioning from Requip to Methadone for restless leg syndrome, experienced medication unavailability due to insurance issues. Staff interviews revealed frequent medication shortages and inadequate pharmacy support. The resident's care plan lacked documentation for managing restless leg syndrome or addressing the missing medications.
A resident with difficulty swallowing was hospitalized for aspiration pneumonia after staff failed to administer medications in crushed form as ordered. Staff relied on incorrect documentation and did not verify medication orders, leading to the resident receiving whole pills. The resident became unresponsive after medication administration, and emergency services found partially dissolved pills in her oropharynx.
A staff member failed to adhere to infection control procedures by assisting a resident in transferring ice from one container to another, leading to cross-contamination when the drink was handed to another resident. This practice was not observed during routine audits, despite being against the facility's food safety policy.
A resident with a history of elopement attempts was not timely evaluated for elopement risk, leading to an elopement incident where the resident took a staff member's car and was involved in an accident. The facility failed to ensure staff were aware of the resident's elopement risk, and the dining room door did not alarm due to the resident removing the Wander guard. The unsecured courtyard and gate facilitated the resident's exit, resulting in hospitalization for injuries.
The facility failed to identify the root cause of falls and implement individualized interventions for two residents, leading to multiple falls and injuries. Staff were unaware of specific fall prevention measures, and care plans were not updated to reflect residents' increased risks and cognitive limitations.
The facility failed to follow prescribed diet textures for two residents, leading to choking episodes and potential risks, and did not adhere to a low carbohydrate diet with double protein for another resident, resulting in increased blood sugar levels and concerns about delayed healing and discharge.
The facility failed to store food in accordance with professional standards by not labeling and dating food items stored in the freezer. Items such as waffles, fish sticks, sliced meat, and shredded/chopped meat were found without proper labeling and dating, contrary to the facility's guidelines.
The facility failed to maintain a clean, well-maintained, and safe environment for its residents. Observations revealed dirty linens, unclean bathrooms, damaged doorknobs, and hazardous baseboard heaters. Maintenance and housekeeping procedures were not consistently followed, leading to these deficiencies.
The facility failed to update care plans for three residents, leading to continued behaviors and repeated falls. One resident had 44 documented behavioral incidents without new interventions, another had eight falls in seven weeks with no care plan updates, and a third had 17 falls over five months with no root cause analysis or updated interventions. Staff interviews revealed that care plans were not consistently reviewed or updated, and communication relied on verbal reports rather than systematic documentation.
The facility failed to ensure a resident's dignity and clean appearance by not providing necessary assistance during meals. A resident was observed struggling to eat, resulting in food debris on his clothing and the floor. Despite other residents using clothing protectors, this resident was not offered one, even though his care plan indicated a decline in functional abilities.
The facility failed to provide necessary behavioral health services for two residents with documented behavioral concerns. One resident had a moderate depressive disorder and exhibited concerning behaviors without receiving mental health evaluations. Another resident displayed frequent behavioral issues, including aggression and yelling, but had no referrals for mental health services despite numerous documented incidents.
The facility failed to provide medical social services for a resident with behavioral concerns. A staff member without a degree admitted to learning on the job and stated that medication changes had not helped the resident's behaviors. No mental health or behavioral health notes, referrals, or counseling were documented, despite 44 incidents of documented behaviors.
A resident with hemiplegia and muscle weakness experienced a 47-day delay in receiving physical therapy services due to the facility's lack of a physical therapist. The resident was making progress in walking before admission, but the delay hindered their ability to stand and pivot. Staff interviews confirmed the absence of a physical therapy program for the past four years.
The facility failed to offer pneumococcal vaccinations to a resident. The resident's medical record showed no evidence of receiving or declining the vaccination. A staff member was waiting for ImMTrax login credentials to verify vaccination status and needed to discuss vaccinations with the resident's POA.
The facility failed to offer COVID-19 vaccinations to a resident, as their medical record did not show any documentation of receiving or declining the vaccination. Staff indicated they were waiting for ImMTrax login credentials and needed to discuss vaccinations with the resident's POA.
Failure to Prevent Resident with Dementia from Entering Other Residents' Rooms
Penalty
Summary
The facility failed to provide necessary services and supervision to a resident diagnosed with dementia who repeatedly entered other residents' rooms, resulting in a physical altercation and minor injuries to another resident. Despite being known to wander and having a history of confusion regarding his own room, the resident continued to access other residents' rooms even after being placed on 1-to-1 observation, then fifteen-minute checks, and eventually residing in a secured memory care unit. Staff interviews and nursing progress notes documented multiple incidents where the resident was redirected after entering other rooms, displaying aggressive behavior, and taking or mishandling other residents' personal items. The facility's policy required appropriate treatment and services for residents with dementia to ensure their highest practicable well-being. However, documentation showed that the resident continued to wander into other rooms and engage in disruptive and aggressive behaviors, including taking items and attempting to dispose of them inappropriately, despite interventions. The facility did not consistently ensure adequate supervision to prevent these incidents, placing both the resident and others at risk for further altercations.
Failure to Prevent Falls in Resident Receiving Psychotropic Medication
Penalty
Summary
The facility failed to identify and implement effective interventions to prevent further falls for a resident with dementia, limited safety awareness, and a known risk for falls. The resident was prescribed psychotropic medications, specifically Ativan, which was recently increased in dosage. Despite the resident's history and increased risk, the care plan contained only minimal fall interventions. The resident experienced multiple unwitnessed falls, including one resulting in head lacerations, and the facility's investigation did not consider the recent increase in Ativan dosage as a contributing factor. Subsequent documentation showed that the resident continued to have increased falls after the Ativan dose was raised, ultimately sustaining a fractured hip. Staff interviews confirmed that the Ativan contributed to the resident's falls and that the medication was not appropriate for the resident's needs. The decrease in Ativan dosage occurred only after the resident had already suffered a serious injury. The facility's lack of comprehensive assessment and timely intervention in response to the resident's changing condition and medication regimen led to repeated falls and significant harm.
Failure to Ensure Effective Medical Director Coordination and Timely Response
Penalty
Summary
The facility failed to ensure that the medical director effectively coordinated medical care, as evidenced by a lack of timely response to nursing staff requests for direction regarding a resident's care. One resident experienced ongoing symptoms, including a severe headache, nausea, and persistent bradycardia, with documented pulse rates as low as 44 beats per minute over several days. Despite repeated attempts by nursing staff to contact the medical director about the resident's slow pulse, calls were not returned promptly, and the resident's condition was not addressed in a timely manner. Interviews with staff revealed that the medical director was only present at the facility once per month and was difficult to reach, with calls often going unanswered for several days. The process for addressing concerns with the medical director's performance was lacking, and there was no established method for managing issues related to the medical director's care of residents. Ultimately, the resident required emergency room care, where new medical orders were provided, including discontinuation of a medication and referral to a cardiologist.
Failure to Maintain Antibiotic Stewardship, Medication Management, and QAPI Program
Penalty
Summary
The facility failed to maintain an effective antibiotic stewardship program and did not ensure the pharmacy delivered medications or completed monthly drug regimen reviews for all residents over a one-year period. Staff reported that medications were not being received as ordered, leading them to obtain medications from a local store when the pharmacy could not supply them. Additionally, drug regimen reviews were inaccessible due to issues with the pharmacy's portal, resulting in no gradual dose reductions for psychotropic medications during the specified timeframe. The facility continued to use the same pharmacy until a new contract could be established, despite these ongoing issues. The facility also lacked a current and updated QAPI (Quality Assurance and Performance Improvement) plan, with the last documented goal dates over two years old. The infection preventionist role was not being fulfilled, as the previous staff member did not complete required duties and the newly hired nurse was not yet certified in infection prevention. QAPI activities were based on survey citations, grievances, and observations, but the plan had not been reviewed or revised in over two years. Staffing challenges were also noted, with one staff member working 11 consecutive days without a day off.
Lack of Designated Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified infection preventionist to oversee the infection prevention and control program. During review of the entrance conference materials, there was no documentation provided to show that a staff member held an infection preventionist certificate or was responsible for the infection control program. In an interview, a staff member confirmed that there was no current staff member with infection preventionist certification, as the previous infection preventionist was no longer employed and the newly hired individual was still completing infection preventionist training.
Deficient Completion and Implementation of POLST Forms and Inconsistent Code Status Documentation
Penalty
Summary
The facility failed to ensure the timely and complete execution of Provider Orders for Life-Sustaining Treatment (POLST) forms for several residents. Specifically, for three residents, the POLST forms were missing required signatures, printed names, or dates in mandatory sections, including the absence of the resident or responsible party's signature and the physician's signature and date. In one case, the form was signed by a physician without verification of who was making life-sustaining choices for the resident. In another, the physician did not print their name or fill in the date, and in a third, the mandatory physician signature and date were left blank, rendering the form invalid according to Montana state requirements. Staff interviews revealed that the process for obtaining physician signatures could be delayed by up to a month, and there was a misunderstanding among staff regarding the validity of unsigned POLST forms. Additionally, the facility failed to ensure consistency in documenting a resident's code status. For one resident, the POLST indicated a Do Not Resuscitate (DNR) status, while physician orders and admission paperwork reflected a full code status, with conflicting information about the authority of the resident's representative to make healthcare decisions. The daily nursing report listed the resident as DNR, but the physician had changed the code status based on the representative's input, despite the representative only having financial, not healthcare, power of attorney. These deficiencies demonstrate lapses in the facility's processes for accurately documenting and implementing residents' treatment preferences and code statuses.
Failure to Ensure Adequate Monthly Pharmacist Medication Reviews and Documentation
Penalty
Summary
The facility failed to ensure that a licensed pharmacist adequately performed and documented monthly medication regimen reviews for several residents receiving psychotropic medications. For one resident, the pharmacist's review did not include all prescribed medications, specifically omitting Ativan, and lacked documentation of the risks versus benefits or rationale for continued use of psychotropic drugs. The physician declined a gradual dose reduction without providing clinical justification, and the resident continued on multiple psychotropic medications for extended periods without documented attempts at dose reduction. Staff interviews revealed concerns that the use of Ativan contributed to the resident's falls, including a hip fracture. Additionally, the facility was unable to provide monthly pharmacist medication regimen reviews for several other residents over the past year. This was attributed to issues with a previous pharmacy provider, which resulted in the facility being locked out of the system and unable to access historical documentation, including pharmacy reviews and recommendations. As a result, there was no evidence that appropriate monthly reviews or recommendations were completed to ensure residents were receiving suitable medications and dosages for their diagnoses.
Failure to Monitor and Appropriately Administer Antibiotics
Penalty
Summary
The facility failed to ensure appropriate antibiotic use and infection control for a resident, resulting in prolonged and overlapping antibiotic therapy without adherence to accepted standards. The resident was prescribed multiple antibiotics over several months, including Bactrim, Vancomycin, Ciprofloxacin, Macrobid, and Cefdinir, often for urinary tract infections (UTIs) and sinusitis. There were instances where two different antibiotics were administered simultaneously for the same UTI, and changes in antibiotic regimens were made without documented rationale. The resident's medication administration records showed overlapping courses and incomplete documentation regarding discontinuation and switching of antibiotics. Additionally, the facility did not have an infection preventionist at the time of the survey, and infection tracking was not performed as required. Staff were unaware of the resident receiving two antibiotics concurrently for the same infection. The resident repeatedly tested positive for Escherichia coli/Extended Spectrum Beta Lactamase (ESBL) in urine cultures and contracted Clostridium difficile during this period. These findings indicate a lack of oversight and monitoring of antibiotic use and infection control practices for the resident involved.
Failure to Timely Report Alleged Abuse and Injuries of Unknown Origin
Penalty
Summary
The facility failed to report allegations of resident-to-resident abuse and injuries of unknown origin to the State Survey Agency as required. In one instance, a resident was found to have fading bruising on the left lower back with no documented falls or injuries in the preceding weeks, and the cause of the bruising was not identified. Staff were unaware of the bruising, no investigation was completed, and the incident was not reported as required. Later, the same resident sustained a fractured hip after a fall that was not witnessed, and the resident was an unreliable reporter. This major injury of unknown origin was also not reported to the State Survey Agency. In another case, a resident was agitated and allegedly hit her roommate, as reported by the roommate, though the incident was not witnessed by staff. The facility investigated the event but determined it was not abuse and did not report the allegation to the State Survey Agency. The facility's policy requires all allegations, including those not yet investigated, to be reported to the administrator and the State Survey Agency, but these incidents were not reported in accordance with policy.
Failure to Complete Required Elements for AMA Discharge
Penalty
Summary
The facility failed to ensure all required elements were completed for a resident who was discharged against medical advice (AMA). The resident's care plan did not include discharge planning until three days prior to the AMA discharge, and the only documentation was the resident's wish to return to the community. There was no evidence of comprehensive discharge planning, education on the risks of leaving AMA, or documentation of provider notification. The only education documented was that the facility could not provide medications to take upon discharge. There was also no record of the provider being notified, no recapitulation of the resident's stay, and no documentation of contact with other entities regarding the risks associated with the AMA discharge. A review of the AMA release form showed it was signed by the nurse and the resident, but lacked a second witness signature and only included a brief handwritten note about the resident's departure. Staff interviews confirmed that education and family contact occurred but were not documented. The facility's policy requires informing the resident and family of risks, notifying the physician, and documenting these actions, none of which were fully completed or documented in this case.
Failure to Provide Transfer Discharge Notice and Bedhold Documentation
Penalty
Summary
The facility failed to provide the required transfer discharge notice and bedhold documentation to a resident who was transferred to the hospital. During an interview, a staff member confirmed that the transfer discharge notice was not present for the resident and acknowledged ongoing issues with providing these notices and bedhold forms. Record review showed that the resident was hospitalized for a period, but there was no documentation of a transfer discharge notice or bedhold form in the resident's record.
Failure to Complete and Implement Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for one resident. The baseline care plan did not identify the resident's code status, omitted active diagnoses contributing to admission, and failed to address risks associated with dementia, weakness, and the use of psychotropic medications. Additionally, the care plan incorrectly indicated no history of falls and lacked a completion date. Required signature sections for both the resident/representative and staff were left blank. Interviews with staff revealed uncertainty about the care planning process and how information from the baseline care plan was communicated to certified nursing assistants (CNAs). Some staff were unaware of how to access the baseline care plan, and one staff member stated that the only care information available was a sheet completed by the DON. The lack of a completed evaluation and missing staff signatures contributed to the incomplete baseline care plan.
Failure to Provide Needed ADL Assistance and Adaptive Equipment During Meals
Penalty
Summary
A deficiency occurred when the facility failed to review and provide the necessary assistance and adaptive equipment for a resident requiring help with activities of daily living (ADLs) during meals. The resident, who had a history of using adaptive utensils and a walled plate due to difficulty handling standard silverware, reported that staff did not feed her properly and that adaptive equipment was not consistently provided. Observations showed the resident struggling to eat independently, unable to grasp food items, and having difficulty using regular utensils and cups without lids, resulting in minimal food and fluid intake during meals. Staff interviews confirmed that adaptive equipment had not been reordered after the resident's recent hospitalization, and the care plan only indicated assistance with eating without specifying the need for adaptive devices. Further observations revealed that meals were left uneaten, and the resident continued to have trouble feeding herself due to the lack of appropriate adaptive equipment and staff assistance. Staff acknowledged that therapy had previously worked with the resident on meal-related ADLs and that she was supposed to receive specific adaptive items and feeding assistance, but these interventions were not consistently implemented after her return from the hospital. The facility did not identify or address the resident's ongoing difficulties with eating, resulting in a failure to ensure she maintained her ability to perform this ADL.
Failure to Accurately Monitor Meal Intake and Address Weight Measurement Errors
Penalty
Summary
The facility failed to accurately monitor and document a resident's meal intake and feeding abilities, as well as address suspected errors in weight measurements, in the context of a resident experiencing severe weight loss. Observations showed that the resident, who had recently returned from two hospitalizations and now required supervision or assistance with eating, was left alone in bed with a meal tray placed out of reach and without any setup or assistance. The resident struggled to feed himself and ultimately consumed very little of his meal, despite documentation indicating he had eaten 76-100% of his lunch. This pattern of inaccurate meal intake documentation was noted over several days. Additionally, the resident's weight records over several months showed a significant and steady decline, amounting to an 11.59% loss over three months. Nutrition notes repeatedly identified possible errors in weight measurements and called for reweighs to verify accuracy, but these discrepancies were not resolved over a six-month period. The resident's weight loss was being monitored, and while some weight loss was considered desirable due to the resident's BMI, the facility did not ensure accurate monitoring of food intake or address ongoing concerns about the accuracy of weight measurements.
Delayed Physician Response to Respiratory Distress and Chest Pain
Penalty
Summary
A resident with a recent history of hospitalization for breathing difficulties experienced chest pain and respiratory concerns over a period of several days. Nursing progress notes indicated that concerns about chest pain were raised by respiratory therapy and the unit manager, and a call was placed to the physician call center. However, there was a significant delay in obtaining new physician orders, with no new orders documented until 19 hours after the initial concern. During this time, the resident continued to exhibit symptoms such as low oxygen saturation, a wet/loose cough, and pleural rub sounds, with oxygen saturation levels dropping as low as 86% on prescribed oxygen. Despite ongoing communication among staff regarding the resident's deteriorating condition, including further drops in oxygen saturation and continued respiratory distress, there was no timely follow-up from the physician. The resident's condition worsened, and he was eventually transferred to the hospital by ambulance after his oxygen saturation fell to 79% while on oxygen. Hospital records confirmed the resident was admitted for acute on chronic hypoxic respiratory failure and other related complications.
Failure to Provide Safe and Effective Pain Management
Penalty
Summary
The facility failed to provide effective pain management and monitoring for a resident, resulting in the administration of more medication than prescribed. Staff interviews and record reviews revealed that the narcotics log book did not accurately reflect the number of fentanyl patches administered, and there was a lack of clear documentation regarding the application, removal, and effectiveness of the patches. Staff members were not fully trained on the facility's medication management process, and one staff member admitted to following procedures from previous employment rather than facility-specific protocols. Additionally, there was no documentation to ensure that the fentanyl patches were in place for the correct duration, nor was there evidence of monitoring for adverse reactions or effectiveness. The resident experienced unmanaged pain, leading to multiple changes in pain medication, including the discontinuation of Norco, initiation of fentanyl patches, and subsequent switches between different dosages and types of pain medications. The medication administration record showed that acetaminophen was given in excess of the prescribed daily limit on one occasion. Progress notes indicated the resident became increasingly lethargic, unarousable, and cold to the touch, ultimately requiring transfer to the emergency room, where a reaction to medication was suspected. The lack of consistent monitoring and documentation contributed to the resident receiving more medication than prescribed and experiencing adverse effects.
Significant Medication Error Due to Misapplied Fentanyl Patch Orders
Penalty
Summary
A significant medication error occurred when a resident was found to have two 50mcg Fentanyl patches applied, despite medication orders specifying the use of either one 50mcg patch or two 25mcg patches only if the 50mcg patches were unavailable. The resident subsequently exhibited increased confusion, including not recognizing her husband and displaying unusual behavior at mealtime. Review of the medication administration record showed the order for two 25mcg patches was only documented as given once, with all other opportunities marked as not applicable, while the 50mcg patch was the standard order. The medication orders were entered with the expectation that staff would understand the conditional use of the two 25mcg patches, but this was not clearly communicated, leading to the error.
Medication Carts Left Unsecured and Unattended
Penalty
Summary
Licensed staff failed to ensure that medication carts were secured and locked when unattended. Multiple observations revealed that medication carts were left unlocked in various locations, including in front of the main nursing desk, in the dining room, and in hallways, with no staff present. On several occasions, pill packets were visibly hanging out of the carts, and drawers were left open. In one instance, a nurse was away from the cart while administering medications, leaving the cart out of sight and unsecured. During another observation, a staff member accessed the narcotics log book and the controlled substance drawer from an unlocked cart, and then left the cart and drawer open while preparing to administer a controlled medication. The staff member asked the surveyor to watch the open cart and controlled medication drawer while they attended to medication administration, only locking the cart and drawer after being prompted by the surveyor. These actions resulted in medications, including controlled substances, being left unsecured and accessible when staff were not present.
Failure to Follow Hand Hygiene and Enhanced Barrier Precautions
Penalty
Summary
Staff failed to follow proper hand hygiene protocols during medication administration, as observed when two staff members did not perform hand hygiene before or after passing medications, including administering an insulin injection. Additionally, the facility did not implement enhanced barrier precautions for two residents: one resident with an unstageable wound connected to a wound vac had no signage or supplies indicating the need for enhanced barrier precautions, and another resident with a physician order for enhanced barrier precautions also lacked appropriate signage and supplies at the door. Interviews with staff confirmed a lack of clarity and adherence to precaution protocols for these residents.
Inadequate Staff Education and Failure to Investigate or Report Abuse Allegations
Penalty
Summary
The facility failed to provide adequate abuse education to administrative staff, resulting in insufficient knowledge regarding the identification and management of abuse allegations, particularly for residents with cognitive deficits. In one instance, a resident with cognitive impairment was found to have scattered, healing bruises on the lower back, accompanied by pain. Nursing notes indicated no falls or injuries during the relevant period, and no investigation was conducted to determine the cause of the bruising. The administrative staff member responsible for abuse investigations was not notified of the incident and had not completed an investigation at the time of the survey. In another case, a resident became agitated and threatened physical harm to a roommate, ultimately hitting the roommate, though the incident was not witnessed. The event was investigated as abuse, but the allegation was not reported as required. The staff member involved had not received abuse training from the facility, and there was uncertainty regarding the training provided by the staffing agency. Documentation of abuse and neglect training for staff was incomplete, with missing dates and unclear instructor qualifications. The facility's policy required reporting of abuse allegations, but this was not consistently followed.
Residents Fear Retaliation Under New Administration
Penalty
Summary
The facility failed to ensure that services were administered in a manner that encouraged residents to report concerns or complaints without fear of retaliation. This deficiency was observed in four of the fourteen sampled residents. The residents expressed concerns about the new administrator's actions and the overall management of the facility, which led to increased anxiety, depression, and isolation among them. Residents reported a decline in morale and a reluctance to participate in activities or eat meals in the dining room. Interviews with residents revealed that the new management, which began in December 2024, was associated with a high turnover rate of staff and unresolved issues raised during resident council meetings. One resident expressed concerns about potential retaliation if they voiced their complaints, while another resident reported increased depression and anxiety, spending more time isolated in their room. The residents' mood assessments indicated a consistent level of depression, with some residents experiencing increased symptoms since the new administrator's arrival. Staff interviews corroborated the residents' concerns, noting that the new administrator's interactions with residents were not positive and that there was an increase in resident behaviors and depression. Staff members observed that some residents were isolating themselves more frequently and not participating in activities. There were also reports of management staff threatening residents with eviction due to their behavior, further contributing to the residents' fear of retaliation and dissatisfaction with the facility's administration.
Medication Availability Deficiency
Penalty
Summary
The facility failed to consistently provide physician-ordered medications for a resident, leading to missed doses of Methadone. The resident, who was being tapered off Requip for restless leg syndrome and switched to Methadone, experienced several instances where the medication was unavailable due to insurance not covering the cost. Staff interviews revealed that the facility had planned to consult with the provider to find an alternative medication covered by insurance, but in the meantime, the facility was paying for the Methadone. Despite these efforts, the resident missed 22 out of 29 scheduled doses in January and 4 out of 19 in February. Interviews with staff members indicated that the facility frequently faced issues with medication availability, and the pharmacy was not helpful in resolving these issues. The facility had conducted an investigation for drug diversion due to missing medications but found no evidence of diversion. Additionally, the resident's care plan did not address the issues related to restless leg syndrome, the use of Methadone, or the missing medications, which meant that staff did not have documented interventions to offer alternate solutions for the resident's condition.
Failure to Administer Crushed Medications Leads to Aspiration Pneumonia
Penalty
Summary
The facility failed to administer medications as ordered by the physician for a resident with a diagnosis of difficulty swallowing, leading to a significant medication error. The resident was supposed to receive medications in a crushed form due to her swallowing difficulties, but staff members administered them whole. This oversight resulted in the resident being transferred to the emergency department and subsequently hospitalized for aspiration pneumonia. Interviews with various staff members revealed a lack of awareness and adherence to the specific medication orders for the resident. A travel nurse and other staff members relied on a document at the nurse's station that incorrectly indicated the resident's medications should be given whole. Despite the resident's known history of swallowing difficulties, staff members did not verify the medication orders and continued to administer the medications whole, assuming the resident would refuse crushed medications. The incident occurred when a staff member administered the resident's medication in applesauce, after which the resident began coughing and became unresponsive. Emergency medical services were contacted, and upon arrival at the hospital, the resident was found to have partially dissolved pills and possibly food in her oropharynx. The resident was diagnosed with severe sepsis, acute on chronic respiratory failure, and aspiration pneumonia, with evidence of food and pill material in her lungs.
Infection Control Breach During Drink Service
Penalty
Summary
The facility failed to ensure proper infection control procedures were followed during drink service, leading to a potential spread of infectious pathogens. During an observation, a resident was seen removing ice with a spoon from her drinking container and placing it into a cup of coffee. Staff member C assisted the resident in this process and then handed the coffee cup to another resident, resulting in cross-contamination. Staff member C admitted to not realizing the cross-contamination had occurred. Staff member G, who conducts weekly audits during meal service, stated that it is not acceptable practice to assist residents in sharing ice cubes. However, she had not observed this practice during her audits. The facility's undated policy on Food Safety Requirements specifies that foods and beverages should be distributed and served in a manner that prevents contamination.
Failure to Manage Elopement Risk Leads to Resident Injury
Penalty
Summary
The facility failed to manage a resident with a known history of elopement attempts, resulting in the resident eloping, sustaining an injury, and being hospitalized. The resident, who had a dementia diagnosis and poor safety awareness, was not evaluated timely for elopement risk throughout his stay. Despite multiple incidents indicating the resident's intent to leave the facility, such as packing belongings and attempting to leave, the facility did not conduct a new elopement assessment after an elopement incident on 8/12/24. A Wander guard was not issued until 8/13/24, and the resident continued to remove it, with no additional interventions implemented to prevent tampering. The facility also failed to ensure staff were adequately informed of the resident's elopement risk. Staff interviews revealed a lack of awareness and understanding of which residents were at risk for elopement and how to identify them. The facility's policy required a systematic approach to monitoring and managing residents at risk for elopement, including staff awareness and communication of interventions, but this was not effectively implemented. Staff were unsure how to identify residents at risk and relied on inconsistent methods to determine if a resident was an elopement risk. The incident culminated in the resident eloping from the facility, taking a staff member's car, and being involved in a vehicle accident. The dining room door, which should have alarmed if a resident with a Wander guard attempted to exit, did not alarm because the resident had removed the Wander guard. The unsecured courtyard and gate facilitated the resident's exit. The resident was found later with injuries and was hospitalized for monitoring. The facility's failure to evaluate the resident's elopement risk timely and ensure staff awareness of the risk contributed to the resident's elopement and subsequent injury.
Failure to Implement Individualized Fall Prevention Interventions
Penalty
Summary
The facility failed to identify the root cause of falls and implement individualized interventions for two residents, leading to multiple falls and injuries. Resident #42 was observed attempting to stand up from his wheelchair and tripped on the foot pedals, nearly falling. Staff indicated that the resident had already fallen earlier that morning and had a history of frequent falls, especially when he had infections or was on antibiotics. Despite 17 falls in five months, including two that required emergency department visits, the resident's care plan did not reflect his increased risk during infections or his cognitive limitations in calling for help. The care plan interventions were generic and did not address the resident's specific needs or behaviors, such as his impulsivity and confusion about his room change. Staff interviews revealed a lack of documentation and communication regarding fall incidents and interventions. Staff member I admitted that the morning fall of resident #42 had not yet been documented, and new interventions were communicated verbally rather than through updated care plans or Kardex. The facility had also discontinued using fall indicators on resident doors and wheelchairs, citing dignity and HIPAA concerns. Staff members were unaware of any fall prevention committee or specific interventions for high-risk residents, indicating a systemic issue in fall management and prevention. Resident #49 also experienced multiple falls, including one that resulted in a head laceration requiring sutures. Observations showed the resident attempting to stand from her wheelchair without assistance, and staff were not always present to intervene. Despite being assessed as a high fall risk, the resident did not have fall prevention indicators on her wheelchair or door. The facility's fall prevention program, which included placing indicators and updating care plans, was not consistently followed. Staff interviews confirmed a lack of awareness and involvement in fall prevention efforts, further highlighting the facility's failure to provide adequate supervision and individualized care to prevent accidents.
Failure to Follow Prescribed Diet Textures and Controlled Carbohydrate Diet
Penalty
Summary
The facility failed to follow diet textures for two residents, leading to documented choking episodes for one resident and potential choking risks for another. Staff member K prepared meals that did not meet the prescribed Soft and Bite-Sized texture, cutting meat with a knife and serving a ham sandwich, which were not approved by the speech therapist or physician. The speech therapy notes and diet orders for both residents specified the need for Soft and Bite-Sized foods, but these were not adhered to during meal preparation, as observed and confirmed by staff interviews and document reviews. Additionally, the facility did not follow a low carbohydrate diet with double portions of protein for another resident, resulting in increased blood sugar levels and concerns about delayed healing and discharge. The resident reported receiving meals high in carbohydrates and lacking the prescribed double protein. Staff interviews revealed that the kitchen used diet cards to guide meal preparation, but these were not consistently followed, leading to the resident's elevated blood sugar levels and lack of necessary protein for healing. Review of the resident's electronic medical record showed significant fluctuations in blood sugar levels, with no notes from a dietician to address these issues. The facility's document on Controlled Carbohydrate Diet emphasized the need for individualized evaluation of blood glucose responses, but this was not reflected in the resident's care. The failure to adhere to prescribed diets and textures posed significant health risks to the residents involved.
Failure to Label and Date Food in Freezer
Penalty
Summary
The facility failed to store food in accordance with professional standards by not labeling and dating food items stored in the freezer. During an observation, several items were found in the freezer that were not in their original containers and lacked proper labeling and dating. These items included a bag of waffles, an open bag of fish sticks, a package of sliced meat, and a package of shredded/chopped meat. The facility's guidelines require that frozen foods be labeled with a 'use by' date 45 days after opening, but this was not adhered to in these instances.
Failure to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to provide a clean, well-maintained, and safe environment for its residents. Observations revealed that several residents had visibly dirty linens, with one resident stating that their sheets were only changed once a week and sometimes had to request changes due to the dirtiness. Another resident had a betadine stain on their linens that had been there for two weeks. Additionally, the CNA classroom toilet was observed to have urine stains and a brownish stain inside the bowl, and the bathroom floor was also stained. The doorknob in one resident's room was falling apart, and the baseboard heaters in the dining area and halls were damaged, with sharp metal pieces sticking out, posing a safety hazard. Maintenance staff were not always aware of these issues, and there was a lack of a consistent system for reporting and addressing maintenance needs. Further observations showed that another resident's bathroom floor was visibly dirty, with a greenish/brown buildup in the toilet bowl. The facility's housekeeping records did not show any reports of the broken baseboard heaters or doorknobs. The facility's housekeeping expectations included daily cleaning of rooms and bathrooms, but these standards were not being met. The facility document titled 'Housekeeping Meeting' outlined detailed cleaning procedures, but the observations indicated that these procedures were not being followed consistently, leading to the deficiencies noted by the surveyors.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to update care plans for three residents, leading to continued behaviors and repeated falls. Resident #36 exhibited 44 documented behavioral incidents over several months, yet his care plan had not been updated with new interventions since the initial revision date. Similarly, Resident #49 experienced eight falls within seven weeks, one of which resulted in a head injury requiring sutures, but no new interventions were added to her care plan. Resident #42 had 17 falls over five months, with a notable pattern of increased falls during infections, but her care plan lacked updated interventions and root cause analysis after the initial implementation date. Interviews with staff revealed that the Assistant Director of Nursing (ADON) was responsible for updating care plans, but nurses were not involved in the revision process. Staff also indicated that care plans were typically revised yearly or more frequently if necessary, but this was not consistently done. The facility relied on verbal reports to communicate new interventions to aides, rather than ensuring all staff reviewed the care plans or Kardex. This lack of systematic updating and communication contributed to the deficiencies observed in the care plans for the three residents.
Failure to Maintain Resident Dignity and Clean Appearance
Penalty
Summary
The facility failed to ensure a resident's dignity and clean appearance by not providing necessary assistance during meals. Resident #42 was observed on two separate occasions struggling to eat, resulting in food debris on his clothing and the floor. Despite other residents using clothing protectors, resident #42 was not offered one. Interviews revealed that the resident had experienced a decline in functional abilities, as indicated in his Significant Change MDS, but the facility did not adjust the care plan to reflect this change and provide the necessary assistance during meals.
Failure to Provide Behavioral Health Services
Penalty
Summary
The facility failed to provide necessary behavioral health services for two residents with documented behavioral concerns. Resident #6 had a PHQ-9 score indicating moderate depressive disorder and a care plan addressing depression related to multiple conditions, including vascular dementia and PTSD. Despite documented behaviors such as exit-seeking, agitation, and suicidal ideation, there were no mental health evaluations or consultations for this resident. Staff interviews confirmed the absence of mental health services for Resident #6, despite several documented incidents of concerning behavior and a request for mental/behavioral health records. Resident #36 exhibited frequent behavioral issues, including yelling, using profanity, and displaying aggression towards other residents. Despite 44 documented incidents of behavioral concerns, there were no referrals or notes for mental health services in the resident's EMR. The care plan for Resident #36 was not initiated until a year after admission and included minimal interventions, such as the addition of Seroquel. Staff interviews confirmed the lack of mental health services for Resident #36, despite ongoing behavioral issues and concerns about the resident's mental health.
Failure to Provide Medical Social Services for Resident with Behavioral Concerns
Penalty
Summary
The facility failed to provide medical social services for a resident with behavioral concerns. During an interview, a staff member who had been employed for about a month and a half admitted to not having a degree and learning on the job. This staff member stated that she intervened when the resident was agitated and had spoken to the doctor about medication changes, which did not help with the resident's behaviors. The staff member also confirmed that there had been no medical social services provided for the resident, and the only changes made were requests for medication adjustments by the doctor. A request for mental health or behavioral health notes, referrals, visits, or counseling revealed that there were no documents available. The resident's electronic medical record (EMR) also lacked notes or referrals for mental health or behavioral health services. A review of the resident's behavior notes showed 44 incidents of documented behaviors over a specified period, including yelling, wanting the police or doctor called, concerns about his brother, refusing outside appointments, agitation, aggression, and anxiety.
Delayed Physical Therapy Services for Post-Stroke Resident
Penalty
Summary
The facility delayed physical therapy services for a post-stroke resident for 47 days after admission. The resident, who had a diagnosis of hemiplegia and hemiparesis following a cerebral infarction, muscle weakness, and repeated falls, was making progress in walking before arriving at the facility. However, due to the absence of a physical therapist at the facility, the initial PT evaluation was not conducted until 47 days post-admission. Interviews with staff revealed that the facility had not had a physical therapy program for the last four years, and the delay in initiating PT was acknowledged as detrimental to the resident's progress in standing and pivoting.
Failure to Offer Pneumococcal Vaccinations
Penalty
Summary
The facility failed to offer pneumococcal vaccinations to a resident. Review of the resident's medical record showed no evidence that the resident had received or declined the pneumococcal vaccination. The resident was admitted to the facility on an unspecified date. During an interview, a staff member stated she was waiting for ImMTrax login credentials to verify vaccination status and needed to discuss vaccinations with the resident's POA.
Failure to Offer COVID-19 Vaccination to Resident
Penalty
Summary
The facility failed to offer COVID-19 vaccinations to one of the five residents sampled for vaccination or declination. Specifically, the medical record of Resident #44 did not show any documentation of receiving or declining the COVID-19 vaccination. Resident #44 was admitted to the facility on an unspecified date. During interviews, a staff member indicated that they were waiting for ImMTrax login credentials to verify vaccination statuses and needed to discuss vaccinations with Resident #44's Power of Attorney (POA).
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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