River Ridge Rehabilitation And Nursing Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Billings, Montana.
- Location
- 1415 Yellowstone River Rd, Billings, Montana 59105
- CMS Provider Number
- 275123
- Inspections on file
- 27
- Latest survey
- January 15, 2026
- Citations (last 12 mo.)
- 29
Citation history
Health deficiencies cited at River Ridge Rehabilitation And Nursing Llc during CMS and state inspections, most recent first.
The facility failed to complete thorough investigations and implement incident-specific interventions following two reported events. In one case, a cognitively impaired resident in a wheelchair was taken outside through an alarmed door by a vendor, preventing the alarm from sounding, and staff were unaware the resident had left until notified by family; the subsequent review focused on door alarms and resident risk factors but did not address the vendor-assisted exit or lack of alarm activation as the root cause. In another case, a resident was found after shift change in urine-soaked clothing and a soiled brief, with the facility later unable to provide complete investigation documentation, interdisciplinary review notes, evidence of staff education, or proof that the resident’s provider and responsible party were notified, contrary to its abuse/neglect policy requiring complete written investigation records and reporting.
A resident eloped from the facility without staff knowledge by exiting through an alarmed door that had been deactivated by a vendor. Following the incident, staff reported that the care plan would be updated after an IDT review, and facility documentation stated the plan would reflect a need for closer monitoring and supervision near exits. However, the actual care plan revision only included adding the resident to an elopement binder, providing education about not leaving without assistance, encouraging use of an enclosed patio, and general wandering/elopement interventions, without specifying closer supervision at exits. This failed to align with the facility’s own elopement policy requiring that risk-related interventions be incorporated into the care plan and communicated to staff.
A resident who required partial/moderate assistance with toileting hygiene and was frequently incontinent of bladder and bowel was found in bed with urine-soaked clothing and a soiled brief after a shift change. Day shift staff discovered the condition while beginning morning care and reported that the off-going night shift staff member, who had been responsible for the resident, did not communicate any need for incontinence care. The resident’s care plan required regular checks for incontinence and prompt peri-care, but this was not carried out, and the facility’s investigation identified a lapse in care by the night shift staff member.
Dietary staff did not consistently wear required hair coverings and beard nets while preparing and serving meals, as observed during multiple meal services. Despite being informed of the policy and ongoing audits, a staff member admitted to frequently forgetting to use the protective attire, resulting in unsanitary food handling conditions.
A resident with significant mobility limitations was left with an as-needed topical medication unsecured at bedside, without proper interdisciplinary assessment for self-administration. Due to the presence of multiple creams on the bedside table, a staff member mistakenly applied the wrong cream, causing the resident temporary discomfort.
A nurse failed to ensure the safe administration of a prescribed topical medication by leaving Triamcinolone Acetonide cream unsupervised at a resident's bedside, resulting in a CNA later applying the wrong cream and causing the resident temporary discomfort. The nurse, new to the facility, did not follow proper procedures for medication administration.
A staff member transferred a resident using a Hoyer lift without the required assistance of a second staff member, despite having received training and education on proper lift protocols. This action was confirmed through interviews and facility documentation, which emphasized the facility's policy requiring two staff for all mechanical lift transfers.
A resident experienced a burning sensation after a staff member applied the wrong topical cream from an unlabeled medication cup left at the bedside. The nurse had placed both the prescribed and an as-needed cream in clear, unlabeled cups without instructions, leading to the error. Facility policy requiring proper medication administration and verification was not followed.
Staff did not follow enhanced barrier precaution protocols during a high-contact transfer of a resident with an indwelling urinary catheter. Two staff members wore gloves but failed to don gowns, resulting in direct contact between their uniforms and the resident. The infection preventionist confirmed that staff are educated to use gowns and gloves for such residents during transfers, as outlined in facility policy.
The facility failed to properly label, date, and store food items in the walk-in cooler and nutrition room refrigerators, leading to potential health risks. Observations revealed unlabeled and expired items, dirty surfaces, and improper temperature monitoring. Staff provided inconsistent information about responsibilities for checking and cleaning the refrigerators, violating facility policies.
A survey revealed multiple infection control deficiencies in an LTC facility, including improper hand hygiene, incorrect use of isolation masks, inadequate equipment sanitization, and failure to follow enhanced barrier precautions. Dietary staff served food with open wounds, and environmental cleanliness was lacking in a resident's room. The facility lacked specific infection control policies and training documentation.
The facility failed to provide written transfer notices to three residents or their representatives when they were transferred to the hospital. One resident was transferred twice for acute changes in condition, another for tingling and involuntary movements, and a third after a choking incident. Staff were unfamiliar with the requirement for written notifications, and no documentation was provided despite requests.
The facility failed to provide required bed hold notices to residents or their representatives before or after hospital transfers. Three residents were affected, with no documentation of notification in their medical records. Staff interviews revealed a lack of understanding and adherence to the facility's policy, which mandates informing residents of the bed hold policy upon admission and prior to transfer.
The facility employed an unqualified activity professional, affecting all residents participating in activities. A staff member hired in September 2024 had not completed or enrolled in an activities professional training program, and her resume confirmed she did not meet the minimum qualifications.
The facility failed to document and manage pressure ulcers for three residents, leading to deficiencies in care. A resident reported pain and had an undocumented coccyx wound, with staff unaware of its duration. Another resident's records showed discrepancies between skin assessments and wound observations, while a third resident had missed wound care sessions and incomplete assessments. The facility's wound care documentation policy was not followed.
Two residents with PEG tubes experienced deficiencies in care due to staff failing to follow physician orders and infection control protocols. One resident received excess fluid during medication administration, while another faced delayed medications affecting meal times and appetite. Staff did not adhere to enhanced barrier precautions or accurately measure fluid volumes, contributing to the deficiencies.
The facility failed to properly label, store, and dispose of medications, with observations of undated medication containers and unattended medication carts. Additionally, the facility did not monitor or document medication refrigerator and freezer temperatures as required by policy, posing risks to medication safety and security.
The facility failed to address maintenance issues in resident rooms and the Rosebud unit, affecting safety and comfort. Two residents reported long-standing issues with broken curtains and windowsills. The maintenance process was inadequate, with poor documentation and overwhelmed staff. The Rosebud medication room had a clogged sink with biofilm and mold, and a missing ceiling tile with exposed cords, with unclear cleaning responsibilities.
The facility failed to ensure the Infection Preventionist had the necessary certification for overseeing the infection control program. A staff member, who began working in February 2024, claimed to have completed the certification in 2019 but could not provide it due to a tornado in another state. The facility documented the need for the certification, but no supporting information was provided to the survey team.
A facility failed to administer pneumococcal and COVID-19 vaccines to a resident, despite having obtained consent for both. A staff member stated that all immunizations were documented in the EHR, but a review showed no record of the vaccines being given. Consent forms confirmed the resident's agreement to receive the vaccines, yet there was no evidence of administration in the EHR.
A facility failed to provide a clean and safe environment for a resident, as surveyors observed persistent unsanitary conditions in the resident's room, including a dried, crusty brown substance near an electrical outlet, stained bedding, and a sticky floor. Staff interviews revealed a lack of awareness and action regarding these issues, and the facility did not provide a housekeeping duty sheet for the resident's room. The resident's care plan emphasized the need for a safe environment due to high fall risk and bowel incontinence, yet these conditions were not met.
A facility failed to complete a comprehensive assessment of a resident's needs within 14 days of admission. The resident, observed with wounds and difficulty eating, did not have these conditions documented in their medical record. The comprehensive admission MDS assessment was 76 days overdue, despite staff acknowledging the requirement for timely submission.
A facility failed to accurately complete the Admission MDS assessment for a resident's oral status. The resident, who had no natural teeth and no dentures since admission, was incorrectly documented as having no broken or missing teeth. Staff interviews confirmed the resident's dental status and ongoing denture fitting appointments, highlighting the need for accurate MDS updates.
A facility failed to implement a comprehensive care plan for a resident with no natural teeth and no dentures, affecting her speech and eating. The resident also had hearing difficulties, wearing one hearing aid and relying on lip-reading. The care plan did not address these issues, and staff were unaware of the status of her dental appointments. Documentation gaps were noted, as dental provider notes were not available by the end of the survey.
A facility failed to update a resident's care plan to include a diagnosis of bipolar depression. Despite a physician's order to schedule a psychiatric appointment and a history and physical confirming the diagnosis, the care plan lacked focus, goals, or interventions for the condition. A PASARR Level II request was submitted, but no documentation showed it was performed. A staff member confirmed that care plans should reflect all current diagnoses.
A facility failed to conduct a trauma-informed assessment for a resident with PTSD, despite her history of abuse and regular nightmares. The resident reported that no discussions about her PTSD had occurred since admission. A staff member deemed the assessment unnecessary, as the PTSD was not an active diagnosis, although it was noted in the PASARR Level II evaluation. Documentation of the assessment was not provided during the survey.
The facility failed to ensure the DON did not work as a charge nurse when the census exceeded 60 residents. The DON was scheduled as a charge nurse on multiple occasions with a census of 69 and 76 residents. The facility's assessment indicated an average daily census of 74.5. The DON acknowledged working more on the floor recently, with plans to hire additional nurses.
A resident reported a cracked wisdom tooth and informed staff, but no dental appointment was scheduled. Staff were aware of the need for a dental cleaning but not the specific issue. Communication was verbal, with no documentation or tracking system in place. The last note on specialty appointments was months old.
The dietary department at the facility was found to be understaffed, leading to meals being served cold and late. Residents experienced delays in meal service, with breakfast often starting significantly later than scheduled. A staff member noted that the facility was short-staffed, and issues persisted despite hiring efforts. Additionally, meals were served at inadequate temperatures, and there was an instance where a cook's absence led to management purchasing alternative meals for residents.
The facility failed to ensure the safe storage of chemicals in an unlocked closet on the Rosebud unit hallway, increasing the risk of resident misuse. A surveyor found the housekeeping closet door unlocked, allowing access to chemical containers with warnings. Staff confirmed the closets should be locked, but the door was not shutting completely, preventing the lock from engaging.
Two residents experienced neglect in the facility, leading to physical and psychosocial harm. One resident was left in soiled conditions and a wheelchair for extended periods, while another had unanswered call lights and was left in a hospital gown for days. The facility failed to report these incidents to the State Survey Agency, contrary to its abuse policy.
The facility failed to address resident grievances and neglect, with multiple residents reporting issues such as unanswered call lights, neglect in personal care, and disrespectful treatment by staff. Staff interviews revealed a lack of understanding and action regarding neglect and abuse allegations, and the facility's grievance logs did not reflect the numerous complaints documented in resident council minutes. The facility lacked a proper system for anonymous grievance filing, and grievances were often not documented or investigated.
The facility failed to protect residents who reported concerns of alleged abuse or neglect and did not report neglect allegations to the State Survey Agency within the required timeframe. Incidents included a resident-to-resident altercation, a resident left in a soiled brief, and a resident not treated with dignity. The facility's policy mandates immediate reporting of such incidents, but these protocols were not followed, leading to the deficiencies noted.
A facility failed to issue a timely refund to a resident's representative, violating its policy of providing refunds within 30 days of discharge. The resident was discharged, but the refund check was delayed and not sent until over a month later, contrary to the facility's Standard Admissions Agreement.
A resident was allowed outside independently without proper assessment, leading to an incident where they were found driving a scooter on a road at night. Staff were unsure of the resident's safety for independent outdoor privileges, and the care plan lacked necessary assessments. The facility's policy was not followed, resulting in the resident leaving against medical advice.
The facility failed to ensure that residents with limited range of motion or mobility received necessary restorative services consistently. Staff were unaware of which residents required these services and lacked a backup plan when the Restorative Aide was unavailable, leading to inconsistent care for four residents.
The facility failed to provide consistent restorative nursing services due to insufficient staffing. The Restorative Aide was often reassigned to work the floor, and there was no backup plan in place. This resulted in significant gaps in the provision of restorative services for four residents, with some receiving services only a few times each month instead of the required three to five times per week.
A staff member failed to provide necessary care for a dependent resident, causing distress and discomfort. The resident, who required substantial assistance with ADLs and was cognitively intact, reported that the staff member refused to help him get out of bed and retrieve his call light, and stretched his urinary catheter tubing. The staff member resigned after the incident was investigated.
The facility did not consistently post daily staffing information as required, with 45 out of 90 days missing postings and inaccuracies in the census updates. A staff member admitted the task was not being performed regularly.
Incomplete Incident Investigations and Lack of Incident-Specific Interventions
Penalty
Summary
The deficiency involves the facility’s failure to conduct comprehensive investigations and implement appropriate, incident-specific interventions following two separate facility-reported events. In the first event, a resident with moderate cognitive impairment (BIMS score of 11) exited the building in a wheelchair through an alarmed entrance door that had been opened by a non-employee vendor, which prevented the door alarm from triggering. Staff were unaware the resident had left the building and only became aware when a family member reported the resident was outside; video surveillance later showed the resident was outside unsupervised for an estimated 15 minutes. The facility’s investigation and documentation identified the resident’s impaired memory, confusion, and desire to smoke as risk factors and focused on staff response to door alarms, but did not accurately identify or address the root cause that the resident was assisted out by a vendor and that no alarm had sounded. In the second event, a resident was found in bed with urine-soaked clothing and a soiled brief by oncoming staff after shift change, following care responsibility by a night-shift CNA. The incident was reported up the chain of command, but the facility was unable to produce documentation showing that the resident’s responsible party or provider had been notified, nor could it provide risk management or event forms with detailed information about the incident. The facility’s written findings referenced interviews with other residents on the hallway, review of security camera footage, the CNA’s resignation, and an interdisciplinary team conclusion that there had been a lapse in care and that the incident was isolated. However, there was no complete and thorough documentation of the investigation, interdisciplinary team notes, event review, staff education, or evidence of required notifications, despite facility policy requiring comprehensive written procedures and documentation for investigations and reporting of alleged abuse, neglect, and exploitation.
Failure to Revise Care Plan After Resident Elopement
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s care plan to reflect current care needs following an elopement. A facility-reported incident submitted to the State Survey Agency documented that resident #67 eloped from the facility without staff knowledge, exiting through an alarmed door that had been deactivated by a facility vendor. Staff interviews indicated that care plans were expected to be updated by nurses or designated staff after such events and on an as-needed basis. The facility’s incident investigation stated that the resident’s care plan was updated to reflect a need for closer monitoring and supervision when approaching facility exits. However, review of resident #67’s care plan entry dated 9/27/25 showed only that the resident was added to an elopement binder, educated not to leave the facility without assistance, and instructed to use an enclosed patio to enjoy the outdoors, along with general interventions such as engaging the resident in purposeful activity, identifying triggers for wandering or eloping, and providing calm, reassuring care. The care plan did not specify the need for closer supervision and monitoring when the resident approached facility exits, as identified in the incident investigation. This omission occurred despite a facility policy on elopements and wandering residents that required interventions to increase staff awareness of a resident’s risk and to minimize associated hazards to be added to the resident’s care plan and communicated to appropriate staff.
Failure to Provide Timely Incontinence and ADL Assistance
Penalty
Summary
Staff failed to respond timely to a resident’s need for assistance with activities of daily living, specifically incontinence care. A facility-reported incident documented that on 6/5/25 at 8:40 a.m., a staff member found resident #99 lying in bed in urine-soaked clothing and a soiled brief. This was discovered by day shift staff members O and L after they completed shift change report with NF3, the night shift staff member responsible for the resident’s care. During interview, staff member L stated that NF3 did not report that the resident needed his brief and clothes changed and that it was not normal routine to leave a resident in a soiled brief or clothing. Resident #99’s MDS, with a quarterly assessment reference date of 5/14/25, showed he required partial/moderate assistance for lower body dressing and toileting hygiene and was frequently incontinent of bladder and bowel. His comprehensive care plan, initiated 3/24/25 for an ADL self-care performance deficit, included an intervention for staff to check him regularly for incontinence episodes and provide prompt peri-care after such episodes. The facility’s interdisciplinary team investigation identified a lapse in care by NF3 related to this incident, during which the resident remained in soiled clothing and a soiled brief without timely incontinence care.
Failure to Ensure Dietary Staff Wore Required Hair and Beard Coverings During Food Preparation
Penalty
Summary
Dietary staff failed to follow safe and sanitary food handling practices by not consistently wearing required hair coverings and beard nets while preparing and serving meals in the facility kitchen. Observations showed a staff member working at the kitchen grill and serving area without a hair covering or beard net, and again dishing food onto plates for resident meals without the appropriate protective attire. The staff member admitted to frequently forgetting to wear the required coverings, citing being new to the cook position and getting busy as reasons for non-compliance. Interviews with another staff member confirmed that all dietary staff are expected to wear hair coverings and beard nets if they have facial hair, and that the staff member in question had been informed of this requirement. The facility's policy on work clothing and attire also mandates a neat, professional appearance and proper attire for employees providing patient care. Despite these expectations and ongoing audits, the deficiency persisted, resulting in a failure to maintain sanitary conditions in food preparation areas.
Failure to Ensure Safe Self-Administration and Secure Storage of Medications
Penalty
Summary
The facility failed to ensure an interdisciplinary team was involved in determining whether a resident was safe to self-administer medication and did not implement a system to secure as-needed medication in the resident's room. A resident with limited mobility and minimal movement in her hands and arms was left with a sample of Blu Emu cream in a medication cup on her bedside table, without a locked container for secure storage. The resident did not use the cream, and it remained on her bedside table. On one occasion, a staff member left a white cream, ordered by the medical provider for underarm application, on the resident's bedside table. Later, another staff member mistakenly applied the Blu Emu cream instead of the prescribed white cream to the resident's underarm, resulting in a temporary burning sensation. The resident's medical record showed that the medication self-administration assessment was not reviewed by the facility's interdisciplinary team, and the facility's policy requiring assessment of the resident's ability to self-administer and secure storage of medications was not followed.
Failure to Safely Administer Topical Medication
Penalty
Summary
Facility nursing staff failed to meet professional standards of practice by not ensuring the safe administration of a scheduled topical medication for one resident. A nurse received an order for Triamcinolone Acetonide cream to be applied under the resident's right and left underarms for skin irritation. Instead of applying the cream as ordered, the nurse placed the medication in a clear 30cc medication cup and left it unsupervised on the resident's bedside table, intending to return later to apply it. The nurse was new to the facility and stated she had previously worked in states where certified nursing assistants (CNAs) were permitted to apply topical creams, but could not explain why she left the medication at the bedside. Later that evening, a CNA assisted the resident in preparing for bed and, at the resident's request, applied a cream from a cup found on the bedside table. The resident experienced a burning sensation under her right arm after the application, prompting the CNA to attempt relief with a cold cloth and then to wash the area with soap and water, which alleviated the discomfort. The resident clarified that the cream applied was blue and had been left at her bedside by a nurse days earlier for muscle soreness, while the prescribed white cream remained unused. The medication administration record indicated the Triamcinolone Acetonide cream was documented as administered, but the nurse failed to ensure it was safely and correctly applied.
Failure to Follow Two-Person Transfer Protocol with Hoyer Lift
Penalty
Summary
A staff member failed to follow established facility protocols for the safe transfer of a resident using a Hoyer lift. Specifically, the staff member transferred a resident from a wheelchair to bed at night without the required assistance of a second staff member. This action was reported by the resident through a grievance, and the staff member later confirmed during an interview that he performed the transfer alone because he could not find another staff member to assist. Facility records and staff interviews confirmed that all staff are educated and trained on the requirement that two staff members must be present for all resident transfers involving mechanical lifts, including Hoyer and sit-to-stand lifts. Documentation showed the staff member involved had completed competency training on the use of these lifts and had received in-service education on proper transfer protocols. Despite this, the protocol was not followed during the incident involving the resident.
Unlabeled Topical Medications Lead to Incorrect Application and Resident Discomfort
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure the safe administration of a scheduled topical medication for one resident. A staff member, while assisting the resident to bed, applied a blue cream from an unlabeled medication cup left at the bedside, instead of the prescribed white cream. The blue cream had been previously left at the bedside by a nurse for muscle soreness, per a provider order allowing it to be kept at bedside. After application, the resident experienced a burning sensation under her right arm, which was only relieved after the staff member washed off the cream and applied the correct white cream as requested by the resident. The nurse had placed two unlabeled medication cups, one with white cream (Triamcinolone Acetonide) and one with blue cream (Blue-Emu), on the resident's bedside table without providing instructions or labeling. The staff member who applied the cream was not given guidance on which cream to use. Facility policy requires that only licensed or permitted individuals prepare, administer, and document medications, and that the right medication, resident, dosage, time, and route be verified before administration. These steps were not followed, resulting in the resident receiving the wrong topical medication and experiencing temporary discomfort.
Failure to Use Enhanced Barrier Precautions During Resident Transfer
Penalty
Summary
Staff failed to follow enhanced barrier precaution protocols during a high-contact care activity involving a resident with an indwelling urinary catheter. During a transfer from bed to wheelchair using a sit-to-stand lift, two staff members wore gloves but did not don gowns, despite their uniforms coming into direct contact with the resident's upper and lower body. The resident confirmed that staff typically wear gowns and gloves during catheter care but not during transfers. The facility's infection preventionist stated that all nursing staff are educated on the requirement to wear gowns and gloves for residents on enhanced barrier precautions during high-contact activities, including transfers. Facility policy, revised in April 2024, specifies that staff should wear gloves and gowns during such activities for residents at increased risk of carrying resistant organisms, such as those with indwelling medical devices. One staff member acknowledged not wearing a gown during the transfer, citing a busy environment.
Food Storage and Cleanliness Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food storage and cleanliness, as observed in multiple instances. In the walk-in cooler, several food items, including cheese slices, Cool Whip, and a tub of red liquid, were found without labels or dates. The cooler's floors and shelves were also dirty, with splatter marks and debris. Staff member S admitted that leftover fruit should have been discarded and that the rice, which was actually chicken soup, was not properly labeled. The facility's policy requires all items to be labeled and dated, with a discard date set seven days from opening. In the nutrition room refrigerator on the Yellowstone Hall, a personal lunch box was found, along with open containers of chip dip and a carafe of yellow liquid, all without labels or dates. Moldy noodles and vegetables were observed in the sink drain. Staff member S acknowledged that the soup in the nutrition room was the same as the rice in the walk-in cooler and should not have been there. The facility's policy mandates that all foods in the refrigerator or freezer be covered, labeled, and dated, and that partially eaten food should not be kept. The Rosebud unit's resident food refrigerator was found with several unlabeled and expired items, including a cold brew coffee can, a bottle of diet Pepsi, and a bottle of Brisk iced sweet tea. The refrigerator's thermometer was improperly placed and stuck in a sticky substance. Staff members Q, O, and C provided conflicting information about who was responsible for checking and cleaning the refrigerator. The facility's policy requires that refrigerator temperatures be monitored and recorded, and that food items be labeled with a 'use by' date. The Rosebud Refrigerator Temperature Log showed temperatures outside the acceptable range and missing entries, indicating a lack of proper monitoring and maintenance.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to proper infection control practices, as observed during a survey. Staff members were noted to neglect hand hygiene protocols, such as changing gloves and using hand sanitizer after handling soiled items and before touching clean items or residents. This was evident in multiple instances, including when staff members changed a resident's brief and prepared medications without proper hand hygiene. Additionally, some staff members were observed handling medications with ungloved hands and moving in and out of resident rooms without doffing gloves or performing hand hygiene. One staff member admitted to not receiving any hand hygiene education at the facility. The use of isolation masks was also improperly managed. Staff members were seen touching their masks and not wearing them correctly, even during a COVID-19 outbreak. Equipment sanitization was another area of concern, with staff failing to disinfect items like medication cart cords and glucometers after use. Enhanced barrier precautions were not followed during enteral medication administration, with staff only wearing gloves instead of the required protective equipment. Dietary infection control was compromised as well, with staff serving food while having open wounds that were not properly covered. The facility lacked a specific infection control policy for the dietary department, and there was no evidence of infection control training for some staff members. Environmental cleanliness was also an issue, with persistent unclean conditions in a resident's room, including dried substances on the wall and floor. Housekeeping staff were expected to clean daily, but there was no documentation to verify this was done consistently.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to provide written notice of the reason for a facility-initiated transfer to three residents or their representatives. Resident #18 was transported to the hospital on two occasions for acute changes in condition, but the medical record did not show any written notice of the transfer was provided. During an interview, a staff member admitted to being unfamiliar with the federal regulation and facility policy regarding written notifications for transfers. Despite requests for documentation, no transfer notifications were provided for these hospital transfers. Similarly, resident #64 was transferred to the hospital for tingling and involuntary movements, but there was no written notice of transfer provided. The resident confirmed not receiving any paperwork. Additionally, resident #78 was hospitalized after a choking incident and did not return to the facility, yet no documentation of the transfer notice was provided. A staff member acknowledged the lack of completed transfer notices as a trend that needed addressing. The facility's policy requires a discharge/transfer form and other documents to be reviewed with the resident or representative, but this was not adhered to in these cases.
Failure to Provide Bed Hold Notices
Penalty
Summary
The facility failed to provide the required bed hold notice to residents or their representatives prior to or shortly after a transfer to a hospital or therapeutic leave. This deficiency was identified for three residents out of a sample of 36. Resident #18 was transported to the hospital on two occasions, and there was no documentation in the medical record indicating that the resident or their representative was notified of the bed hold policy. During an interview, a staff member admitted to not knowing who was responsible for the bed hold documentation or how the process worked. Despite requests for documentation, no bed hold notifications were provided for resident #18's hospital transfers. Similarly, resident #64 was transferred to the hospital, and the medical record did not show that the resident or their representative was notified of the bed hold policy. The resident confirmed in an interview that they did not sign or receive any paperwork. Resident #78 was hospitalized after a choking incident and did not return to the facility. The facility failed to provide documentation of the bed hold policy notification for this resident as well. A staff member acknowledged that the notifications were not being completed and recognized it as a trend that needed to be addressed. The facility's policy requires that residents be informed of the bed hold policy upon admission and prior to transfer, but this was not adhered to in these cases.
Unqualified Activity Professional Employed
Penalty
Summary
The facility failed to employ a qualified activity professional to direct the activity program, which may affect all residents participating in activities. During an interview, a staff member stated she was hired in September 2024, but had not completed and was not currently enrolled in an activities professional training program. A review of her resume confirmed that she did not meet the minimum qualifications required to direct the activity program.
Inadequate Documentation and Management of Pressure Ulcers
Penalty
Summary
The facility failed to accurately document and manage pressure ulcers for three residents, leading to deficiencies in care. Resident #57 reported pain and had a coccyx wound that was not documented in her electronic health record (EHR) until after a surveyor inquiry. Staff members were unaware of the wound's duration, and there was a lack of wound assessments in the EHR. An interview revealed that the resident had been in painful positions and her brief was not changed frequently, contributing to the development of the wound. Additionally, there was inconsistency in weekly skin assessments and wound documentation, indicating a need for staff education. Resident #11's records showed discrepancies between weekly skin assessments and wound observations, with a Stage 4 pressure ulcer documented but not reflected in the skin assessment. Similarly, Resident #76 had a Stage 4 pressure ulcer that was not consistently documented, with missed wound care sessions and incomplete weekly skin assessments. The facility's wound care documentation policy was not followed, as evidenced by the lack of recorded wound care details in the residents' medical records.
Deficiencies in PEG Tube Management and Infection Control
Penalty
Summary
The facility failed to adhere to physician orders and proper procedures for residents with PEG tubes, leading to deficiencies in care. For resident #3, a staff member administered medications through a PEG tube without accurately measuring and recording the total fluid volume, exceeding the physician's order of a maximum of 150 mL by administering at least 185 mL. Additionally, the staff member did not check the placement of the PEG tube after it moved, which was a recurring issue, and continued to administer medications despite feeling resistance, attributing it to the syringe tip. Resident #20 experienced delays in medication administration, which affected his meal schedule and appetite. His medications, scheduled for early morning, were often given late, leading to a mismatch between meal and medication times. This resident also experienced significant weight loss over a few months. During medication administration, staff failed to follow enhanced barrier precautions, did not check PEG tube placement, and did not flush the tube as per physician orders. Medications were not properly dissolved, and the total fluid volume was not measured or recorded. The facility's staff demonstrated a lack of adherence to infection control protocols and physician orders, particularly concerning hand hygiene and enhanced barrier precautions. Staff members were observed not removing gloves or sanitizing hands between tasks, and medications were administered without proper flushing or checking of PEG tube placement. These actions contributed to the deficiencies noted in the care of residents with PEG tubes.
Medication Management and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications, as well as the disposal of expired medications. During an observation, a medication cart was found with scattered loose pills and several opened and undated medication containers, including stool softener, Vitamin B Complex, Zinc, Folic Acid, Senna, Aspirin, Milk of Magnesia, and Mylanta. Staff confirmed that opened medication bottles should be dated and replaced within 30 days, but this was not adhered to. Additionally, a nasal spray had an opened date written over its expiration date, obscuring the information. Furthermore, a medication cart was left unattended with medication cards on top, and a Handihaler Device was found on the floor, indicating lapses in medication security and handling. The facility also failed to monitor and document medication refrigerator and freezer temperatures. Observations revealed that the Rosebud unit medication room refrigerator lacked temperature logs, and a request for temperature logs from July to October 2024 was not fulfilled. The facility's policy requires daily temperature checks and documentation, but this was not followed. Additionally, a medication cart was observed unlocked and unattended in a hallway, with the nearest nurse out of view, posing a risk of unauthorized access to medications. These deficiencies highlight significant lapses in medication management and storage protocols within the facility.
Maintenance and Sanitation Deficiencies in Resident Rooms and Medication Room
Penalty
Summary
The facility failed to address maintenance issues in residents' rooms and the Rosebud nursing unit area, compromising the safety, functionality, and comfort of the environment. Two residents reported long-standing maintenance issues in their rooms. One resident had broken curtains that had been non-functional for over a year, preventing them from adjusting the light in their room. Another resident reported a broken windowsill that had been in disrepair since they moved into the facility over two years ago. Despite informing staff members about these issues, the problems remained unresolved. The maintenance process at the facility was found to be inadequate. Staff member G, responsible for maintenance, acknowledged the lack of proper documentation and communication regarding maintenance requests. The maintenance book contained only three requests, none of which addressed the issues reported by the residents. Staff member G admitted to being overwhelmed with responsibilities, including maintenance for both the nursing home and an assisted living facility nearby, and noted difficulties in retaining additional maintenance staff. The Rosebud unit's medication room was observed to be in a state of disrepair and unsanitary conditions. The sink in the medication room was clogged, with standing water and various substances, including biofilm and mold, present. The room also had a missing ceiling tile with exposed cords and a water-stained ceiling tile. Staff interviews revealed that the sink had been non-functional for a significant period, and there was confusion about cleaning responsibilities. Despite the sink's condition, there was no signage indicating it should not be used, and maintenance records for the sink were not provided during the survey.
Infection Preventionist Certification Deficiency
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist had the necessary certification to oversee the infection control program. During an observation, a staff member stated that she began working at the facility in February 2024 and had completed the infection preventionist certification in 2019. However, she was unable to provide the certification due to a tornado in another state that resulted in the loss of the document. The facility's request sheet, dated November 7, 2024, documented the need for the Infection Preventionist Certification, but no certification or supporting information was provided to the survey team before the survey concluded.
Failure to Administer Vaccines Despite Consent
Penalty
Summary
The facility failed to provide pneumococcal and COVID-19 vaccines to a resident, despite having obtained consent for both vaccinations. During an interview, a staff member indicated that all immunizations were documented in the Electronic Health Record (EHR), and no additional documentation existed outside of the EHR. However, a review of the resident's EHR showed no record of the vaccines being administered. Consent forms dated 9/24/24 confirmed that the resident had agreed to receive both the pneumococcal and COVID-19 vaccines, yet there was no evidence in the EHR that these vaccines were given. The resident's immunization records were requested the following day.
Failure to Maintain a Clean and Safe Environment for a Resident
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for a resident, as evidenced by multiple observations of unsanitary conditions in the resident's room. On several occasions, surveyors noted a dried, crusty brown substance near an electrical outlet next to the resident's bed, which persisted over multiple days. Additionally, a large amount of white, dried crusted substance was observed on the resident's bedding, and the privacy curtain next to the resident's recliner had dark brown, dried stains. The floor alongside the resident's bed was sticky with debris, and new stains appeared over time, indicating a lack of thorough cleaning. Interviews with staff revealed a lack of awareness and action regarding the cleanliness issues. A staff member speculated that the brown substance might be chocolate pudding, while another thought it resembled feces stains. The staff member responsible for changing the resident's bed sheets did not notice the stains, and it was noted that curtains in resident rooms were not regularly changed or replaced. Despite the facility's housekeeping protocol, which included cleaning resident rooms and floors, the requested housekeeping duty sheet for the resident's room was not provided during the survey. The resident's care plan highlighted the need for a safe environment due to high fall risk and bowel incontinence, yet the observed conditions contradicted these requirements.
Failure to Complete Timely Comprehensive Assessment
Penalty
Summary
The facility failed to complete a comprehensive assessment of a resident's needs, strengths, goals, life history, and preferences within 14 days of admission for one of the sampled residents. During an observation and interview, the resident was noted to have wounds on both legs and the left arm, and was having difficulty eating, with their left hand resting in the food on their plate. Despite these observations, the facility's documentation did not indicate any medical conditions, including wounds, for the resident. The resident's medical record showed that the comprehensive admission MDS assessment was due 14 days after admission but remained incomplete and unsubmitted 76 days past the due date, as of the last day of the survey period. A staff member confirmed that initial admission MDS assessments are supposed to be conducted and submitted within the required timeframe, but this was not done for the resident in question.
Inaccurate MDS Assessment of Resident's Oral Status
Penalty
Summary
The facility failed to accurately complete the Admission Minimum Data Set (MDS) assessment for a resident's oral status. During an observation and interview, it was noted that the resident had no natural teeth and no dentures, which the resident confirmed had been the case since her admission. The resident had her teeth removed prior to admission and had not yet been fitted with dentures. Despite this, the Admission MDS assessment inaccurately indicated that the resident had no broken or missing teeth. Interviews with staff confirmed that the resident had no teeth upon admission and had attended several appointments for denture fittings. The staff member responsible for MDS assessments acknowledged the need to update and ensure the accuracy of the resident's MDS information.
Failure to Implement Comprehensive Care Plan for Resident with Dental and Hearing Needs
Penalty
Summary
The facility failed to implement a comprehensive, resident-centered care plan for a resident who had no natural teeth and no dentures, which affected her ability to speak clearly and eat comfortably. The resident expressed embarrassment and difficulty in communication due to the absence of teeth and was awaiting dentures, which were delayed due to jaw problems. Despite being on a bite-sized diet, the resident still faced challenges in eating. Additionally, the resident had hearing difficulties, wearing one hearing aid and relying on lip-reading for communication. During the survey, it was found that the resident's care plan, initiated in September, did not address her dental, eating, dietary modifications, or hearing difficulties. Staff interviews revealed a lack of awareness and documentation regarding the resident's dental appointments and the status of her dentures. The facility was unable to provide dental provider notes by the end of the survey, indicating a gap in the documentation and follow-up on the resident's care needs.
Failure to Revise Care Plan for Mental Health Diagnosis
Penalty
Summary
The facility failed to revise an individualized comprehensive care plan to include a mental health diagnosis for a resident with bipolar depression. The resident's physician's order, dated 10/3/24, indicated the need to schedule an appointment with Encounter Telehealth Psychiatry for bipolar disorder and depression. However, the care plan initiated on 9/3/24 did not include any focus, goals, or interventions related to the diagnosis of bipolar depression. The most recent history and physical, dated 1/30/24, confirmed bipolar depression as an active diagnosis. Additionally, the facility had submitted a letter requesting a PASARR Level II for the resident on 9/13/24 due to the history of bipolar depression, but there was no documentation provided by the end of the survey period to show that a PASARR Level II was performed. During an interview, a staff member stated that care plans should be completed upon admission, quarterly, or with any change in a resident's condition and should reflect all current diagnoses.
Failure to Conduct Trauma-Informed Assessment for Resident with PTSD
Penalty
Summary
The facility failed to conduct a trauma-informed assessment for a resident diagnosed with post-traumatic stress disorder (PTSD). The resident, who had a history of abuse, reported experiencing regular nightmares and stated that no one from the facility had discussed her PTSD since her admission. Despite the resident's PTSD diagnosis being noted in her PASARR Level II evaluation, a staff member believed a trauma-informed assessment was unnecessary because the PTSD was not considered an active diagnosis. A psychiatric telehealth note indicated that the resident was seen for an initial consultation for PTSD treatment. However, the facility did not provide documentation of a trauma-informed assessment before the survey concluded.
DON Worked as Charge Nurse Despite High Census
Penalty
Summary
The facility failed to ensure that the Director of Nursing (DON) did not work as a charge nurse when the average daily census exceeded 60 residents. This deficiency was identified through a review of nursing schedules and census records, which showed that the DON, referred to as staff member B, was scheduled to work as a charge nurse on multiple occasions when the census was 69 and 76 residents. Specifically, staff member B worked as a charge nurse on the day shift from 6-12 on 4/27/24, from 3-6 on 4/28/24, and on the night shift from 10-6 on 10/4/24. The facility's assessment tool indicated an average daily census of 74.5 residents. During an interview, staff member B acknowledged working on the floor more frequently in the past week and a half, but mentioned that the facility planned to hire two more nurses to alleviate this issue.
Failure to Provide Dental Services for a Resident
Penalty
Summary
The facility failed to provide necessary dental services for one resident, who reported a cracked wisdom tooth. The resident expressed that she had informed multiple staff members about her dental concerns but was not aware of any scheduled appointment. Staff member E acknowledged awareness of the resident's need for a dental cleaning but was unaware of the specific issue with the wisdom tooth. Communication regarding the appointment was reportedly verbal, and no documentation or tracking system was in place to ensure the appointment was scheduled or completed. Staff member E admitted to not documenting meetings with residents regularly and was behind on quarterly meetings. Additionally, staff member E did not specifically inquire about the need for dental appointments during interactions with residents. The last documented note regarding specialty appointments for the resident was dated several months prior.
Dietary Department Staffing Deficiency
Penalty
Summary
The dietary department at the facility failed to provide sufficient staffing to safely and effectively carry out the functions of the food and nutrition services. This deficiency was observed through multiple instances of meals being served cold and late to residents. On several occasions, residents were observed waiting for breakfast well past the scheduled meal time, with breakfast service starting significantly later than planned. Staff member S, who was responsible for serving meals, expressed concerns about being short-staffed and mentioned that the facility had recently hired one dietary staff member, but issues persisted due to staff absences and resignations. Further observations revealed that meals were not only served late but also at inappropriate temperatures. For instance, a staff member checked the temperature of sausage on a tray and found it to be 106 degrees Fahrenheit, which was acknowledged as inadequate. Additionally, there was an incident where a cook did not show up, leading to management purchasing pancake platters for residents as a substitute meal. Staff member S highlighted the ongoing challenge of managing meal services with insufficient personnel, resulting in meals being consistently delayed by 30 minutes or more for over a month.
Unsafe Storage of Chemicals in Unlocked Closet
Penalty
Summary
The facility failed to ensure the safe storage of chemicals in an unlocked closet on the Rosebud unit hallway, which increased the risk of resident misuse of the chemicals. During an observation, a surveyor found that a housekeeping closet door was closed but unlocked, allowing access without a code or key. Inside the closet, there were three chemical containers with Ecolab labels, each displaying warnings and first aid precautions. Staff member V confirmed that the housekeeping and janitor supply closets were supposed to be locked when not in use, but the door could be opened without a code or key. Further observations and interviews revealed that the door to the Rosebud unit hallway housekeeping closet was not shutting completely, preventing the lock from engaging properly. Staff member U also confirmed that the doors to these closets, which contain cleaning supplies and chemicals, should be locked and closed when not in use. Despite requests for documentation or policies on securing housekeeping or maintenance rooms, no such documentation was provided by the end of the survey.
Neglect of Residents Leading to Harm
Penalty
Summary
The facility failed to protect two residents from neglect, resulting in physical and psychosocial harm. Resident #15 experienced neglect when a staff member refused to change his brief, leaving him in soiled conditions for an extended period. This neglect led to skin breakdown and pain. The resident was also left in a wheelchair for six hours, causing back pain and concern about pressure sores. Despite complaints from a family member, the staff member continued to work with residents, and the incident was not reported to the State Survey Agency. Resident #1 was not treated with dignity and respect, as evidenced by unanswered call lights and being left in a hospital gown for five days. The resident's call light was on for extended periods on multiple occasions, leading to distress and a request for immediate discharge. The facility did not respond to the grievance filed by the resident's family, and the neglect was not reported to the State Survey Agency. The facility's abuse policy requires immediate reporting of neglect, but the administrator failed to report these incidents. The administrator was unaware of the requirement to report neglect, believing only abuse and misappropriation of funds needed reporting. This lack of reporting and failure to follow protocol contributed to the ongoing neglect of residents.
Failure to Address Resident Grievances and Neglect
Penalty
Summary
The facility failed to promptly resolve grievances brought forth by residents, provide a means for anonymous grievance filing, and ensure thorough investigations into grievances. Multiple residents reported issues such as unanswered call lights, neglect in personal care, and disrespectful treatment by staff. For instance, one resident was left in a hospital gown for five days and did not receive a timely refund, while another resident's call lights were not answered for extended periods, leading to distress and discomfort. Staff interviews revealed a lack of understanding and action regarding neglect and abuse allegations. The administrator admitted to not knowing the requirement to report neglect and failed to document or investigate complaints. Residents expressed frustration over the lack of response to their grievances, with some being told to stop complaining or to consider moving out if they were dissatisfied. The facility's grievance logs did not reflect the numerous complaints documented in resident council minutes, indicating a systemic issue in grievance handling. The facility's policies on filing grievances and abuse were not adhered to, as evidenced by the absence of investigations and corrective actions for reported grievances. Staff members reported grievances to management, but no changes were observed, leading to a perception of management ignoring the issues. The facility lacked a proper system for anonymous grievance filing, and grievances were often not documented or investigated, leaving residents unprotected and their concerns unaddressed.
Failure to Timely Report Alleged Abuse and Neglect
Penalty
Summary
The facility failed to protect residents who reported concerns related to alleged abuse or neglect and did not report neglect allegations to the State Survey Agency within the required 24-hour timeframe for three residents. Additionally, the facility did not report the investigative findings of reported incidents within five days for three residents. Specific incidents included a resident-to-resident altercation where findings were reported late, and a resident left in a soiled brief for an extended period, which was not reported promptly due to improper protocol by staff. Another incident involved a resident-to-resident altercation with delayed reporting of findings. Further deficiencies were noted in the handling of an injury of unknown origin and a resident-to-resident incident, both of which had delayed reporting of final findings. Additionally, a resident was not treated with dignity and respect, with call lights unanswered and left in a hospital gown for several days, which was not reported as neglect due to the administrator's misunderstanding of reporting requirements. The facility's policy mandates immediate reporting of abuse, neglect, and other violations, but these protocols were not followed, leading to the deficiencies noted.
Delayed Refund to Resident's Representative
Penalty
Summary
The facility failed to issue a refund to a resident's representative within the required 30-day period following the resident's discharge. During an interview, it was revealed that the representative did not receive the refund check until over a month after the discharge date. The resident was discharged on May 7, 2024, but the refund check was not sent until June 10, 2024, and was cashed on June 21, 2024. This action was in violation of the facility's Standard Admissions Agreement, which mandates that refunds be made within thirty days of a resident's death, transfer, or discharge.
Failure to Assess Resident for Independent Outdoor Privileges
Penalty
Summary
The facility failed to ensure that a resident was appropriately assessed for independent outdoor privileges and did not ensure the resident was inside the facility at night. This deficiency involved a resident who was given a new scooter and outside privileges without a proper assessment. A nurse expressed concerns about the resident's safety outside, but another staff member had granted the privileges. The resident was later found driving his motorized scooter down a road at night, which led to a motorist contacting the facility. Interviews with staff revealed that there was confusion and lack of communication regarding the resident's leave privileges. Staff members were unsure if the resident was safe to be outside independently, especially at night. The facility's policy required a care plan for independent leave privileges, but the resident's care plan did not include an assessment for outdoor independence or elopement risk. The facility's investigation confirmed that the leave of absence assessment was not completed before the incident, and the resident left the facility against medical advice the following day.
Failure to Provide Consistent Restorative Services
Penalty
Summary
The facility failed to ensure that residents with limited range of motion or mobility received the necessary restorative services to maintain their highest level of functioning. This deficiency was identified for four residents who were supposed to receive restorative services. Staff interviews revealed a lack of awareness and coordination regarding which residents required these services and when they were provided. Specifically, staff members were unsure how to ensure restorative services were delivered, especially when the Restorative Aide (RA) was pulled to work the floor due to staffing shortages. There was no clear backup plan or system in place to track and assign these services in the Electronic Health Record (EHR), leading to inconsistent and inadequate care for the residents in need of restorative services. Resident #1 was supposed to receive ambulation and range of motion services three to five times per week to maintain strength and mobility. However, the resident's records showed no restorative services provided in February, only two instances in March, and three in April. Similarly, Resident #3, who was a fall risk and required assistance with all activities of daily living, was supposed to receive restorative services three to five times per week. The records indicated no services in February, only one instance in March, and three in April. Resident #8, who had limited range of motion and required assistance with transferring to and from his electric wheelchair, also received inconsistent restorative services, with nine instances in February, two in March, and two in April. Resident #13, who had contractures and required restorative services to maintain his range of motion, showed similar inconsistencies. The resident received services nine times in February, twice in March, and three times in April. The facility's policy stated that residents would receive restorative nursing care as needed to promote optimal safety and independence, but the lack of a coordinated system and backup plan resulted in these residents not receiving the necessary care consistently. Staff members were unaware of any tasks in the EHR to facilitate the provision of restorative services when the RA was unavailable, leading to a failure in maintaining the residents' highest level of functioning.
Insufficient Staffing for Restorative Nursing Services
Penalty
Summary
The facility failed to ensure there was sufficient staffing available to consistently provide restorative nursing services for four residents. Interviews with staff members revealed that the Restorative Aide was frequently pulled from their duties to work the floor due to short staffing, resulting in the lack of consistent restorative services. Staff members indicated that there was no backup plan in place when the Restorative Aide was reassigned, and the switch from electronic health records (EHR) to paper charting further complicated the identification of residents needing restorative services. Review of the Restorative Care Flow Record for the affected residents showed significant gaps in the provision of restorative services. In February, two residents did not receive any restorative services, while in March and April, all four residents received services only a few times each month, far below the required frequency of three to five times per week. This deficiency had the potential to affect any resident identified as needing restorative nursing services.
Staff Member Fails to Assist Dependent Resident
Penalty
Summary
A staff member failed to provide necessary care and services for a dependent resident, causing the resident to become upset and tearful. The incident involved a resident who required substantial assistance with activities of daily living (ADLs) and was cognitively intact. The resident reported that the staff member refused to assist him in getting out of bed to a chair and also refused to retrieve his call light. Additionally, the staff member stretched the resident's urinary catheter tubing, causing discomfort. The staff member involved voluntarily resigned following the investigation of the incident.
Failure to Post Daily Staffing Information
Penalty
Summary
The facility failed to post the required daily staffing information consistently and accurately, as mandated. A review of the facility's daily staff posting information from 1/22/24 to 4/23/24 revealed that 45 out of 90 days were missing postings. Additionally, none of the 45 postings received included the name of the facility, and 11 were missing the number of hours actually worked. The facility also failed to update the census to reflect admissions accurately, with only three days showing the appropriate increase in census out of 26 days with at least one admission. During an interview, a staff member acknowledged the inconsistency in posting and admitted that the task was not being performed regularly.
Latest citations in Montana
A resident with a history of hematuria, renal failure, anemia, and recent blood transfusions was readmitted from the hospital with discharge instructions to pause apixaban, but the facility failed to obtain admission orders and did not clarify the incomplete anticoagulant order. The resident’s care plan did not address anticoagulant use or monitoring, and staff administered multiple doses of apixaban after readmission. Nursing notes documented blood in the nephrostomy drainage bag on two days without provider notification or intervention, followed by worsening weakness, poor intake, and hypoxia that led to hospital transfer. Hospital records showed the resident had gross hematuria, hypotension, respiratory distress, acute kidney injury, and a critically low Hgb requiring transfusion, and a late entry note acknowledged that the discharge order to hold apixaban had been overlooked.
A resident who was cognitively intact but dependent for bowel and bladder care and limited in ROM reported that a specific staff member repeatedly left call lights unanswered for extended periods, causing the resident to soil briefs and then be pressured to ambulate to the bathroom and sign refusal-of-care forms. A family member corroborated long call-light waits and rude interactions, and staff noted the resident became anxious and displayed behaviors when care was forgotten or incomplete. Despite verbal reports, emails, and documentation at a care conference describing long call-light waits, incontinence episodes, and refusal forms used at night, no grievance was filed and the alleged neglect was not reported or investigated. The resident also developed unaddressed skin issues on the heels, coccyx, and ears, and +2 pitting edema in both feet and ankles, with offloading devices found unused in the room and no related wound orders or documented weekly skin assessments.
Multiple residents experienced inadequate pressure ulcer and skin care when staff failed to perform timely and accurate skin assessments, obtain and follow wound care orders, and implement appropriate care plan and nutritional interventions. One resident admitted with multiple skin issues developed a large, foul-smelling coccyx ulcer that was not promptly evaluated, lacked early wound orders, and was not reflected in the care plan or consistently documented on the TAR. Another resident with a coccyx pressure injury and a spinal incision had delayed wound measurements, late dietitian notification, missed daily wound treatments, and late addition of protein supplementation to the care plan. A resident using oxygen had painful, reddened ears and heel/eschar issues that were not captured in admission documentation, lacked wound orders, and had no subsequent skin assessments recorded. A further resident with a coccyx pressure ulcer had conflicting MDS staging and "present on admission" coding, along with numerous days where ordered daily wound care was undocumented or absent. Staff interviews revealed inconsistent weekly skin checks, missed admission skin evaluations due to EHR changes, limited dietitian availability, and wound care being performed by staff without formal wound training, all contrary to the facility’s own skin integrity policy.
The facility failed to thoroughly investigate, monitor, and document multiple abuse allegations involving staff-to-resident and resident-to-resident incidents. In one case, a resident reported that a staff member blew marijuana vape smoke in his face, but there was no related nursing documentation or post-incident monitoring. In another case, a resident reported being hit by another resident, was found with a red mark on the head, and was sent to the ER, yet nursing notes for both residents lacked documentation of the incident and follow-up monitoring. In a third case, a cognitively impaired resident with developmental delay was found in another resident’s room while that resident’s hands were being removed from inside the resident’s pants and shirt, after which the resident complained of pain and was sent to the ER; again, nursing notes for both residents contained no documentation of the event or post-incident monitoring, and the investigator did not fully interview or obtain written statements from all involved as required by facility policy.
The facility failed to thoroughly investigate multiple allegations of abuse and neglect, including one resident’s report that a staff member was verbally demeaning and rushed her during oral care, and another resident’s report of inadequate ADL care with prolonged call light response times and being left in a soiled brief. A staff member admitted not reporting or investigating the latter allegation, and no related documentation was produced. In a separate incident, a resident alleged a CNA turned off the call light and refused requested personal care; the facility interviewed only the involved staff and did not interview other residents who might also have experienced call lights being turned off without care being provided, despite a witness stating this was a common practice by multiple staff. Additional requested interviews and information were not provided to surveyors.
Surveyors found that the facility failed to complete timely and comprehensive baseline care plans for three newly admitted residents. One resident with multiple serious conditions and a coccyx wound had no baseline care plan addressing wound care, pain, or chronic conditions for several days after admission. Another resident with dysphagia, dementia, and documented skin issues on the buttocks, heels, and knee had a baseline care plan that did not identify pressure wounds or related treatments. A third post‑surgical resident with a Stage 3 pressure ulcer and a lumbar incision had a baseline care plan that omitted wound management and post‑operative pain control. A staff member reported that baseline care plans are only generated after the admission nursing assessment is completed and locked, and acknowledged they are not always completed on time.
A resident’s long-time friend, a former employee previously terminated over an abuse allegation, was barred from entering the facility when she attempted to visit, and was told law enforcement would be called if she returned. Another individual confirmed awareness of the restriction, expressed no concern about the friend abusing the resident, and stated that the facility did not offer supervised or common-area visits. A staff member reported that any former employee terminated for an abuse allegation was categorically prohibited from returning to the building, without considering the resident’s relationship with the visitor, despite a visitation policy stating residents have the right to receive visitors of their choice and allowing only limited or supervised access when abuse is suspected or found.
The facility failed to follow its grievance policy by not documenting or investigating a grievance request from a resident and family member alleging that a CNA ignored call lights for extended periods, failed to provide timely ADL care, forced ambulation to the bathroom at night, and pressured the resident to sign refusal-of-care forms, causing the resident to feel afraid and neglected. In a separate case, the facility did not adequately investigate or document a grievance from a dependent, mobility-impaired resident who reported that a male CNA was rough and refused to reposition his contracted legs for comfort, and the staff member assigned to the investigation did not identify the CNA involved or record her explanation of the situation on the grievance form.
A resident reported that a former staff member repeatedly left the call light unanswered for extended periods, did not provide needed ADL assistance, and encouraged the resident to sign refusal-of-care forms, resulting in the resident soiling briefs before being asked to ambulate to the restroom. Another staff member stated that no care concerns had been brought to their attention and acknowledged that the alleged abuse and neglect were not reported. When surveyors requested IDT notes, root cause analysis, reporting, and investigation documents related to the staff member and this resident, the facility was unable to provide any documentation, indicating the allegation was not timely reported to the State Survey Agency or investigated.
Surveyors found that several residents did not receive appropriate ADL and hygiene assistance or accurate documentation of those services. A dependent resident reported inconsistent help with meals, only sponge baths instead of showers for several weeks, lack of shaving, and prior grievances about staff not assisting with a urinal or repositioning his legs. Another cognitively intact resident, dependent for oral care and dressing, stated he was not offered mouthwash or a warm washcloth, and staff confirmed they had never offered mouthwash despite charting that personal hygiene was provided. A third resident, largely independent with self-care, reported that washcloths were not available unless requested, and no washcloths were seen in the room, while documentation showed staff performing most of her personal hygiene. These findings showed failures to offer basic hygiene items and to accurately document ADL care provided.
Failure to Clarify Anticoagulant Orders Leads to Unnecessary Drug Administration and Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s drug regimen was free from unnecessary drugs when nursing staff did not clarify and correctly implement anticoagulant orders upon the resident’s readmission. The resident had been hospitalized for hematuria, renal failure, and anemia, received multiple blood transfusions, and was discharged back to the facility with an After Visit Summary instructing that apixaban (an anticoagulant) be paused, with no restart date specified. Despite this, the facility’s admission documentation for the readmission date showed no admission orders, and the apixaban order was not clarified with the physician. The medication was restarted and administered after readmission, even though the hospital documentation indicated it was to be paused and later discontinued. Following readmission, the resident’s Medication Administration Record showed that seven doses of apixaban were given. The resident’s care plan, initiated on the readmission date, did not identify any problems, goals, or interventions related to anticoagulant use, safety, or monitoring for side effects. Nursing progress notes documented that the resident had a right-sided nephrostomy with yellow urine drainage on the day of readmission, and then documented blood in the nephrostomy drainage bag on two consecutive days. However, there was no documentation that the provider was notified about the hematuria or that any action was taken in response to this change. Subsequently, nursing notes described the resident as weak, not eating, unable to maintain a sitting position, and having low oxygen saturation that did not adequately improve with increased supplemental oxygen, leading to transfer to the emergency department. Hospital records from that visit showed the resident presented with hypoxia, hypotension, profound weakness, respiratory distress, gross hematuria, acute kidney injury, and a critically low hemoglobin of 6.9 g/dL, and that the resident had received an anticoagulant and required blood transfusions. A late entry nursing note at the facility later documented that the hospital discharge summary had been overlooked, the order to hold apixaban was not implemented, and the resident continued to receive apixaban until readmission to the hospital. The facility’s root cause analysis attributed the event to ambiguity in discharge communication and medication reconciliation workflow and noted that the apixaban order was incomplete and not clarified before administration.
Failure to Identify and Address Neglect, Call-Light Delays, and Skin Concerns
Penalty
Summary
The deficiency involves the facility’s failure to identify, report, and address neglect of care concerns for a cognitively intact resident who was dependent on staff for bowel and bladder care and had range of motion limitations in both upper and lower extremities. The resident reported that a specific staff member (NF7) repeatedly left his call light on for extended periods, often over 45 minutes and up to hours at night, resulting in him soiling his brief with bowel and bladder incontinence while waiting for assistance. When staff eventually responded, NF7 would attempt to have the resident ambulate to the restroom despite the resident already being incontinent, and would then encourage him to sign refusal of care forms when he declined. The resident described being upset, anxious, and irritable, and stated he usually “peed” and “soiled” his pants and developed skin issues from sitting so long without being cleaned. A family member (NF6) corroborated concerns about long call light response times, stating the resident’s call light was left on for over an hour, leading to incontinence episodes, and that NF7 spoke to the resident in a rude and angry manner. NF6 reported these concerns in person, by phone, and by email to facility staff, including staff members A and C. Staff member O reported that the resident had anxiety and behaviors that were exacerbated when staff forgot about him or failed to perform all required care. Despite these reports and the resident’s expressed fear and anxiety when NF7 was working, no staff member asked the resident if he felt safe or explored what had occurred on nights with or without NF7, and the alleged neglect was not reported or investigated by facility leadership. The resident also had unaddressed skin concerns and edema that were not properly identified or managed. Staff member B stated weekly skin assessments should have been done but that wound care staff were unaware of any ear or coccyx issues, and the physician orders lacked wound orders for the resident’s left heel. On assessment, staff member P observed eschar on the left heel that appeared to need debridement, redness and cracking on the right heel, pink coccyx, and reddened ears, with delayed capillary refill on one ear, as well as +2 pitting edema in both feet and ankles that had developed during the resident’s stay. Posey boots intended to offload the heels were found in the resident’s cabinet, and staff member P stated she had never seen them used on the resident. Additionally, at a care conference documented and signed by staff member C, the resident reported waiting 20–40 minutes for call lights at night, having accidents while waiting, and being made to sign refusal papers when he declined to go to the bathroom after already being wet. Despite this documentation of neglect-related concerns, no grievance was filed, and staff members B and C stated they were unaware of or did not report or investigate any alleged abuse or neglect for this resident.
Failure to Assess, Document, and Treat Pressure Ulcers and Related Skin Conditions
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain an effective system for pressure ulcer prevention, identification, assessment, and treatment for multiple residents. For one resident admitted with existing skin issues on the buttocks, both heels, and a right knee wound, nursing notes documented a silicone foam dressing on the coccyx that was saturated with foul-smelling brown-yellow drainage, and a non-stageable pressure ulcer with slough, black eschar, and a large reddened border. This was the first detailed description of the coccyx pressure ulcer, and there were no wound care orders in the chart at that time. A subsequent weekly skin evaluation described a large, deep coccyx wound with copious foul-smelling drainage and extensive slough and granulation tissue, but incorrectly listed that date as the first observation despite the wound being identified nine days earlier. Wounds on the left heel, right outer ankle, and right knee were not evaluated until several days after admission, and the right heel was never evaluated during the stay. The resident’s care plan did not identify pressure ulcers as a problem and contained no interventions for pressure ulcer care or nutrition to support wound healing, and the treatment administration record showed wound treatments were not ordered until several days after admission and were then not consistently documented as completed. Another resident was admitted with a coccyx area that was open and possibly caused by pressure, and a late entry note identified a Stage 3 pressure ulcer to the coccyx from admission. However, the nutrition evaluation form later indicated “no” to the presence of a pressure injury and instead listed “other skin condition,” even though coccyx wound care was ordered. The weekly skin evaluation documented the first observation and measurements of the coccyx wound two weeks after admission, and the dietitian was not notified until several days after that. The treatment record showed that daily wound care orders for both the coccyx pressure ulcer and a surgical spine incision were not carried out on at least two days. Nutritional interventions to support wound healing, including a protein supplement, were not added to the care plan until more than two weeks after the wound was identified. Staff interviews revealed that the dietitian was only present in the facility limited hours on two days per week, that residents admitted later in the week might not be assessed nutritionally until the following week, and that a fourteen-day delay in nutritional assessment, while allowed, was acknowledged as not best practice for residents with wounds. A third resident using oxygen reported pain behind both ears, and observation showed that oxygen tubing protectors had slid out of place, leaving the ears unprotected. The right ear was red where the tubing rested, and the left ear was very red with a whitish substance in the crease. Staff later described this resident’s skin as having eschar on the left heel that appeared to need debridement, a red and cracked right heel, a pink coccyx, and reddened ears, with the left ear showing slower capillary refill. The facility’s records contained no wound orders for the left heel, no skin assessments since the most recent readmission, and an admission nursing evaluation that documented the skin as warm, dry, intact, and without wounds. A fourth resident had a coccyx pressure ulcer that was present on admission and gradually decreasing in size according to wound assessments. However, MDS assessments contained inconsistent documentation: one assessment showed no unhealed pressure ulcers on admission, a later discharge assessment documented a Stage IV pressure ulcer present on admission, and a subsequent quarterly assessment documented a Stage III pressure ulcer not present on admission. Treatment administration records showed no coccyx wound treatment in one month, initiation of daily wound care late in the following month with at least one missed documented treatment, and in the next month, daily wound care orders with more than half of the scheduled treatments lacking documentation of completion. In the subsequent month, the TAR failed to show any wound care performed for the coccyx pressure ulcer. Staff interviews indicated that weekly skin checks were the facility practice but were not consistently completed, that nurses were not always coding or documenting wounds correctly, and that admission skin evaluations were sometimes not done due to issues with a new computer system. A staff member performing wound care on one resident’s coccyx reported having no formal wound training and described a wound bed fully covered with thick yellow-tan slough, which, according to the cited National Pressure Ulcer Advisory Panel guideline, could not be accurately staged, despite the facility’s practice of staging it as a Stage III pressure ulcer. The facility’s own Skin Integrity policy required that upon admission, the licensed nurse establish a plan of care based on risk factors or presence of wounds, conduct ongoing weekly full-body skin audits, document new skin impairments with detailed characteristics and measurements, record qualifying wounds on the weekly skin evaluation form, notify the medical provider and obtain treatment orders, notify the resident or representative, notify the registered dietitian, and implement and document appropriate care plan interventions. The findings across these residents showed that these policy steps were not consistently followed: admission and weekly skin evaluations were missed or delayed, wounds were not accurately or timely documented or staged, treatment orders were delayed or not consistently carried out, nutrition and care plan interventions for wound healing and prevention were not promptly implemented, and staff responsible for wound care sometimes lacked formal wound training.
Failure to Thoroughly Investigate and Document Multiple Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to complete thorough investigations, monitoring, and documentation for multiple abuse allegations. In one incident, a resident reported that a staff member blew marijuana vape smoke in his face. The staff member later admitted to vaping marijuana in the resident’s room. Despite this, the resident’s nursing progress notes for the period following the incident contained no documentation of the event or any post-incident monitoring, and the psychosocial impact assessment tool indicated that no ALERT charting had been done by nursing or social services. In a second incident, a resident sitting in a wheelchair by the nurse’s station told a staff member that another resident had hit him; assessment revealed a red mark on the resident’s head, and the resident was sent to the emergency room at the family’s request. However, nursing progress notes for both the alleged victim and the alleged aggressor for the days following the incident contained no documentation of the incident or any post-incident monitoring. The staff member responsible for the investigation stated that he relied on video footage and interviews with the two residents, but these interviews were only documented in the incident report, and no other staff or residents on shift were interviewed. In a third incident, staff found one resident in another resident’s room and observed the second resident removing his hands from inside the first resident’s pants and shirt; the first resident later stated, “It hurts down there,” and was sent to the emergency room. The first resident had diagnoses including unspecified symptoms involving cognitive functions and awareness, anxiety, depression, cerebral infarct, and was described as having a developmental delay with the mentality of an 8-year-old, while the second resident was cognitively intact based on a BIMS score of 14. Nursing progress notes for both residents for the days following the incident contained no documentation of the event or any post-incident monitoring. The staff member overseeing the investigation acknowledged that he did not document his post-incident checks, did not interview staff on shift or other residents, and no abuse education or protective measures for staff were documented, contrary to the facility’s abuse prevention policy that requires interviews with all involved, retrieval of written statements, and documentation of assessments and monitoring.
Failure to Thoroughly Investigate Allegations of Abuse and Neglect
Penalty
Summary
The deficiency involves the facility’s failure to fully investigate multiple allegations of abuse and neglect, including not identifying all potentially affected residents. One resident reported that a staff member (NF8) was “nasty and pushy” while assisting with oral care, telling her she should not take so long brushing her teeth because she only had eight teeth and making her hurry without giving her the time she needed. When the facility questioned NF8 about this incident, he resigned from his position. Review of the facility-reported incident showed no staff interviews were completed as part of the investigation, despite the importance of such interviews in understanding the incident and identifying root causes. Another resident reported inadequate ADL care by staff member NF7, including long call light response times and being left in a soiled brief for hours, and stated he had reported these concerns to facility staff. A staff member later stated they were unaware of any concerns from the resident or his family regarding NF7 and acknowledged they did not report or investigate the alleged abuse or neglect. When surveyors requested documentation such as interdisciplinary team notes, root cause analysis, reporting, and investigation related to concerns with NF7, none was provided. In a separate facility-reported incident, a resident alleged a CNA turned off the call light and refused to provide requested personal care. The facility interviewed only the staff involved that night and did not interview other residents who might have been affected by staff turning off call lights without providing care. A witness (NF5) reported that it was the facility’s usual practice to turn off call lights without providing help, that staff often told the resident they would return but did not always do so, and that multiple staff engaged in this behavior. Despite a request from surveyors, the facility did not provide additional resident interviews or information regarding this allegation by the end of the survey.
Failure to Complete Timely Baseline Care Plans for Wounds and Pain Management
Penalty
Summary
The deficiency involves the facility’s failure to complete timely and comprehensive baseline care plans that provided instructions for resident-centered care for three residents. One resident was admitted with multiple serious diagnoses, including acute kidney failure, anemia, atrial fibrillation, chronic respiratory failure, hypertension, a right femur fracture, morbid obesity, and muscle weakness. A nurse progress note documented a coccyx wound described as stage I open on the day of admission, yet no baseline care plan was initiated to direct staff in caring for the wound, managing pain, or addressing the resident’s chronic medical conditions. A care plan was not started until several days later, and when it was initiated, it only addressed advanced directives, oral/dental health problems, loneliness, and discharge planning, without including wound or pain management. Another resident was admitted with dysphagia, dementia, behaviors, a history of falls, and a urinary tract infection. Nursing progress notes documented skin issues on the buttocks, both heels, and the right knee, but the baseline care plan initiated the same day did not identify pressure wounds or any treatment for those wounds. A third resident, admitted after surgical repair of a lumbar 4 compression fracture, had a documented Stage 3 pressure ulcer and a lower back incision with intact staples on the admission nursing evaluation. However, the baseline care plan for this resident did not include wound management interventions or pain management for post-operative pain. During an interview, a staff member explained that the baseline care plan is triggered when the admitting nurse completes and locks the admission nursing assessment, and acknowledged that when assessments are not locked, baseline care plans are not completed and are not always done on time.
Failure to Honor Resident’s Right to Chosen Visitor
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to receive visitors of her choosing. A long-time friend of the resident, identified as NF1, reported that when she first attempted to visit the resident after the resident’s admission, staff member B escorted her out of the building and told her that law enforcement would be called if she returned. NF1 had previously been employed by the facility approximately four years earlier and had been terminated due to an allegation of abuse toward a resident. The facility did not allow her to visit the resident in any capacity. Another individual, NF2, stated he was aware that the facility was not allowing NF1 to visit the resident and that he knew about the prior abuse allegation but was not concerned about NF1 abusing the resident. NF2 stated he wanted NF1 to be allowed to visit and that the facility did not offer supervised visits or visits in a common area. He was hesitant to raise the visitation issue with the facility because he was concerned it might change how the resident was treated. Staff member B confirmed that any employee terminated due to an abuse allegation was not allowed to return to the building for any reason, and that this restriction was applied without considering the resident’s history with the visitor. The facility’s visitation policy stated residents have the right to receive visitors of their choice and that limitations may include denying or limiting access to individuals suspected of abuse until an investigation is completed or abuse is found, but the facility applied a blanket prohibition in this case.
Failure to Document and Investigate Resident Grievances Alleging Neglect and Inadequate Repositioning
Penalty
Summary
The deficiency involves the facility’s failure to follow its grievance policy and to ensure residents could voice grievances related to alleged abuse and neglect without discrimination or reprisal. One resident reported that a specific CNA (NF7) left his call light on for hours, did not assist with ADLs, and that this led to bowel and bladder incontinence while he waited for help at night. The resident stated that when the CNA finally responded, the CNA would force him to ambulate to the restroom instead of cleaning him in bed, and when the resident refused to ambulate, the CNA told him to sign a refusal of care form. The resident reported being afraid of this CNA and feeling neglected in his care, and he stated he reported these concerns to staff member C. An external email from NF6 to staff member C documented that the resident was afraid of NF7, described NF7’s statements about his job duties, and explicitly requested to file a grievance and have NF7 kept away from the resident. Additionally, a care conference note signed by staff member C documented the resident’s report of being made to sign refusal sheets at night and waiting 20–40 minutes for call lights to be answered. Despite this, staff member C, identified as the grievance official, stated there were no concerns brought forth from the resident or family regarding NF7, and no grievance was completed for this abuse/neglect allegation as required by the facility’s grievance policy. The deficiency also includes the facility’s failure to thoroughly investigate and document findings for another resident’s grievance regarding care. This resident, who had impaired mobility in both upper and lower extremities and was dependent for all ADLs except eating, reported that a night CNA was rough and refused to reposition his legs, and he stated he had complained to the facility but the issue continued. A written grievance from this resident documented that a male CNA would not readjust his legs for comfort. The grievance form’s investigative findings did not show any attempt to identify the specific night CNA involved or to clarify what care was being refused. Staff member E, who was responsible for investigating this grievance, could not recall details of the investigation and acknowledged she did not attempt to identify the accused CNA, characterizing the issue as a recurrent complaint and a miscommunication about repositioning due to the resident’s leg contractures. She stated she had encouraged the resident to be more specific about the repositioning requested but could not explain why this was not documented on the grievance form. The facility’s grievance policy required that grievances, including those involving abuse or neglect, be documented on a grievance form and investigated, but this was not done in accordance with policy for these residents’ complaints.
Failure to Timely Report Alleged Abuse and Neglect to State Agency
Penalty
Summary
The facility failed to timely report an allegation of abuse and neglect to the State Survey Agency involving one sampled resident, identified as resident #47. During an interview, resident #47 reported that a specific former staff member, NF7, would leave his call light on for hours, fail to assist with ADL care, and this lack of response resulted in the resident soiling his brief with bowel and bladder because he waited so long for help. The resident further stated that NF7 would encourage him to sign a refusal of care form and then expect him to ambulate to the restroom after he had already gone in his brief. In a separate interview, staff member B stated that no care concerns from the resident or family had been brought to their attention and acknowledged that they did not report the alleged abuse or neglect of care. A request by surveyors for documentation related to resident #47’s interdisciplinary team notes, any identified root causes, reporting, and investigation of concerns involving NF7 and resident #47 yielded no documentation by the end of the survey, demonstrating a lack of evidence that the allegation was reported or investigated as required.
Failure to Provide and Accurately Document ADL and Hygiene Assistance
Penalty
Summary
Surveyors identified that the facility failed to provide and accurately document assistance with activities of daily living (ADLs) for multiple residents. One resident, who was assessed on the MDS as dependent for all ADLs except eating (requiring only partial to moderate assistance with eating), reported not always receiving help with meals, having only sponge baths for several weeks instead of showers, and needing a shave while observed lying in bed in a hospital gown with several days of facial hair growth. This same resident had previously filed a grievance stating that a night nurse would not assist with use of a urinal despite his inability to do this himself, and that a male CNA would not readjust his legs for comfort. These findings showed a lack of consistent ADL assistance for a resident documented as dependent. Surveyors also found failures related to personal hygiene supplies and documentation for two other residents. One cognitively intact resident, dependent for oral hygiene and dressing, stated he had not been offered mouthwash or a warm washcloth to wash his face that day, and no mouthwash was present in his room; staff later confirmed they had never offered him mouthwash, despite documentation that personal hygiene was offered and that staff did most of the activity. Another resident, who stated she could wash her face, brush her teeth, and comb her hair mostly independently, reported that washcloths were never available unless she specifically asked staff, and on observation there were no washcloths in her room. Her EHR documentation showed staff did most of her personal hygiene activity, while staff later stated she was generally independent and that they had not been giving her a daily washcloth. These discrepancies demonstrated inaccurate ADL documentation and failure to routinely offer basic hygiene items such as washcloths and mouthwash.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
