Sheridan Memorial Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Plentywood, Montana.
- Location
- 440 W Laurel Ave, Plentywood, Montana 59254
- CMS Provider Number
- 275070
- Inspections on file
- 20
- Latest survey
- August 5, 2025
- Citations (last 12 mo.)
- 25
Citation history
Health deficiencies cited at Sheridan Memorial Nursing Home during CMS and state inspections, most recent first.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents. The environment did not meet safety standards, and there was insufficient oversight in the area.
The facility did not have a grievance policy that included instructions for anonymous submissions and failed to post the grievance officer's contact information. Two residents were unaware of how to file grievances or where to find forms, and staff handled concerns verbally without documentation. The available drop box was labeled for suggestions, not grievances, and the written policy lacked guidance on anonymous submissions.
The facility did not maintain required documentation showing the Medical Director or designee's attendance at QAPI meetings, as only one instance of attendance was recorded over several months. Staff confirmed that meetings occurred and that the Medical Director or designee sometimes participated via video conferencing, but there were no sign-in sheets or consistent records to verify this, resulting in a failure to meet regulatory requirements for QAPI committee documentation.
Staff failed to perform required hand hygiene before and during medication administration for multiple residents, including handling dropped medication and touching various surfaces and resident items without sanitizing hands or equipment, contrary to facility policy and infection control standards.
A resident with chronic atrial fibrillation and on Coumadin therapy returned from the hospital with a critically elevated INR and a large hematoma. Despite hospital instructions to hold Coumadin, the medication was continued in the LTC facility due to a communication breakdown and lack of nursing follow-up, resulting in the resident receiving unnecessary doses. Staff did not question the order or notify the provider as required by facility policy.
A resident with a documented history of PTSD and significant past trauma did not have their diagnosis, triggers, or appropriate interventions identified in their care plan. Staff were aware of the resident's trauma history and triggers but lacked a process to communicate this information, and the resident's MDS assessment did not reflect the PTSD diagnosis. No trauma-informed care assessment or social history was available, resulting in a failure to provide trauma-informed and culturally competent care.
A resident with severe cognitive impairment and on a pureed diet lost his upper partial denture, and the facility did not promptly refer him to dental services or offer a replacement. The resident experienced significant weight loss, and staff interviews revealed a lack of awareness and documentation regarding the missing denture.
A facility failed to report an allegation of verbal abuse by a staff member towards a resident within the required 24-hour timeframe. The incident was reported internally on the day it occurred but was not submitted to the State Survey Agency until five days later. The staff member responsible for reporting could not explain the delay, and the facility's policy lacked specific reporting timelines.
A resident was not included in care plan meetings, despite being cognitively intact and expressing a desire to participate. The resident's electronic medical record lacked documentation of invitations to these meetings. A staff member confirmed that while family members were contacted, the resident was not invited, and no documentation of such invitations was maintained.
A facility failed to identify bilateral grab bars as a potential restraint for a resident, neglecting to complete a risk assessment, obtain consent, or implement restraint monitoring. Observations showed grab bars on the resident's bed, and interviews indicated possible consent due to the resident's fall history. However, the medical record lacked necessary documentation, and staff noted the grab bars were not used as assistive devices. The facility's policy stated restraints would not be used for convenience.
A facility failed to ensure a pharmacist monitored a resident's as needed psychotropic medication for excessive duration. The resident received lorazepam for over 14 days without the pharmacist addressing the issue with the medical provider, contrary to facility policy. A staff member was unaware of the prolonged order, highlighting a lapse in monitoring and communication.
A facility failed to limit a resident's PRN lorazepam order to 14 days without documented rationale from a provider. The resident's MAR showed lorazepam was administered twice, but the order remained active beyond the 14-day limit. A staff member was unaware of the ongoing order, and the pharmacist did not identify or address the issue during medication regimen reviews. The facility's policy required PRN psychotropic orders to be limited to 14 days and used only for specific, documented circumstances.
A resident with a history of elopement and confusion managed to leave the facility unsupervised, resulting in a fall and facial injuries. Despite staff efforts to redirect him, the resident exited the building by catching the main door before it latched. The facility's Roam Alert System was unreliable, and staff had become desensitized to its alarms. The resident's care plan included interventions for his elopement risk, but these were insufficient to prevent the incident.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified regarding the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to the risk of accidents for residents. Specific actions or inactions leading to this deficiency include the lack of proper hazard identification and insufficient supervision in the affected area. No additional details about specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Provide Accessible and Anonymous Grievance Process
Penalty
Summary
The facility failed to establish and implement a grievance policy that included instructions for submitting grievances anonymously and did not post the grievance officer's contact information in a prominent location. Two residents reported being unaware of the grievance process, how to file grievances anonymously, or where to find or deposit grievance forms. Observations confirmed the absence of posted information identifying the grievance officer and the required contact details. Additionally, the box available for submitting forms was labeled for 'Suggestions' rather than grievances or complaints, and had previously been repurposed, further contributing to confusion. Interviews with staff revealed that the grievance officer had not processed any resident grievances and that concerns were typically handled verbally without documentation. Staff indicated that residents would need to request a grievance form, which was only available electronically and required staff assistance to print. The facility's written policy on complaints and grievances did not include procedures for anonymous submissions. These actions and omissions resulted in a lack of accessible and clear grievance procedures for residents.
Lack of Documentation for Medical Director Attendance at QAPI Meetings
Penalty
Summary
The facility failed to maintain proper documentation of the Medical Director's or designee's attendance and participation in Quality Assurance and Performance Improvement (QAPI) meetings, which are required to occur at least quarterly. Record review revealed that, except for one documented instance in April 2025, there was no evidence of a medical provider or director attending QAPI meetings from September 2024 to March 2025, and from May 2025 to July 2025. Staff interviews confirmed that while QAPI meetings were held monthly (excluding July and December), there were no sign-in sheets to verify attendance, and the facility relied on meeting minutes to record attendees. Staff also indicated that the Medical Director or designee sometimes attended via video conferencing, but this was not consistently documented. The facility's QAPI policy requires the Medical Director to be a member of the committee and for meetings to occur at least quarterly. Despite requests for sign-in documentation to confirm the Medical Director or designee's attendance at required meetings, no such records were provided during the survey. This lack of documentation means the facility could not demonstrate compliance with regulatory requirements for QAPI committee composition and meeting frequency.
Failure to Follow Infection Control Practices During Medication Administration
Penalty
Summary
Facility staff failed to adhere to proper infection prevention and control practices during medication administration for three of four observed residents. Specifically, a staff member did not perform hand hygiene prior to handling or administering medications to multiple residents. In one instance, a medication was dropped onto the medication cart surface, picked up with a plastic spoon, and placed in a medication cup without hand hygiene being performed or the cart surface being sanitized. Additionally, the staff member was observed touching various surfaces and resident items, such as a call light, water cup, and the resident's hand, without performing hand hygiene before administering medications. Interviews with staff confirmed awareness that hand hygiene should occur before and after resident contact, but review of facility training materials revealed no specific training on infection prevention during medication administration. Facility policies on medication administration and hand hygiene require handwashing before medication preparation and administration, and after contact with inanimate objects or glove use, but these procedures were not followed during the observed incidents.
Failure to Hold Anticoagulant After Critical Lab Value Due to Communication Breakdown
Penalty
Summary
The facility failed to recognize, identify, and confirm with a physician the need to discontinue or hold a Coumadin (warfarin) order for a resident who had a critical lab value. The resident, who had chronic atrial fibrillation and was on chronic anticoagulation therapy, returned from the emergency department with a significantly elevated INR and a large hematoma. Despite documentation in the hospital records to hold Coumadin for one week due to the elevated INR, the medication orders in the long-term care facility's electronic medical record remained unchanged, and the resident continued to receive the medication. Nursing staff did not question the continuation of Coumadin, nor did they contact the provider for clarification, even though the facility's policy required provider notification and holding the medication for elevated INR levels. Interviews with staff revealed a communication breakdown between the hospital and the LTC facility, resulting in the hold order not being transferred to the facility's EMR. Staff acknowledged that critical thinking and nursing judgment were not applied, and the Coumadin order was not included in the investigation of the resident's injury, which was attributed to the use of the sit-to-stand lift and the effects of anticoagulation. The facility's policy required prompt provider notification and action for elevated INR, which was not followed in this case.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to identify and address a resident's history of trauma and associated triggers, resulting in a lack of trauma-informed and culturally competent care. The resident had a documented diagnosis of chronic post-traumatic stress disorder (PTSD), with provider notes indicating ongoing treatment and medication adjustments for PTSD and depression. Interviews revealed the resident had a significant trauma history, including an abusive marriage, the loss of a child, and childhood hospitalization. Staff acknowledged that the resident experienced triggers, such as believing her ex-husband was present at the facility, but there was no recent discussion of her PTSD diagnosis among staff due to staff turnover. Review of the resident's care plan showed it did not include the PTSD diagnosis, nor did it identify specific triggers or interventions to prevent re-traumatization. The resident's Minimum Data Set (MDS) assessment did not indicate PTSD as an active diagnosis, and no trauma-informed care assessment or social history was provided upon request. Staff interviews confirmed there was no process to ensure communication of specialized provider diagnoses to staff, contributing to the lack of trauma-informed care planning for the resident.
Failure to Refer Resident for Replacement of Lost Dentures
Penalty
Summary
The facility failed to promptly refer a resident with lost partial dentures to dental services, resulting in the resident going without his upper partial denture. The resident, who had Alzheimer's disease and severe cognitive loss, was on a pureed diet and expressed dislike for the texture. The loss of the partial denture was discovered when the resident's family came to pick him up for a home visit, and staff informed them that the denture was missing. Documentation showed that the denture was reported missing, and a search was conducted, but there was no evidence that a referral to dental services was made or that replacement was offered. Review of the resident's records indicated a significant weight loss of 15% over six months. The facility's policy stated that it is responsible for lost dentures when the resident is not competent or has dementia. However, staff interviews revealed that some were unaware the denture was missing, and no documentation was provided to show follow-up or referral to dental services before the end of the survey.
Failure to Timely Report Verbal Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of verbal abuse within the required 24-hour timeframe. The incident involved a staff member allegedly verbally abusing a resident before 8:00 a.m. on October 5, 2023, and was reported internally to another staff member at 11:30 a.m. the same day. However, the initial report to the State Survey Agency was not submitted until October 10, 2023, five days after the incident occurred. During an interview, the staff member responsible for submitting abuse allegations to the state was unable to explain the delay, despite being aware of the required reporting timelines. Additionally, the facility's abuse policy, dated August 27, 2023, did not specify the reporting timelines for incidents to the State Survey Agency.
Resident Excluded from Care Plan Meetings
Penalty
Summary
The facility staff failed to include a resident in care plan meetings, which is a deficiency in allowing residents to participate in the development and implementation of their person-centered plan of care. During an interview, the resident expressed that she was not invited to any care plan meetings, although her family members were. The resident indicated a desire to attend these meetings. A review of the resident's electronic medical record showed no documentation of her being invited to participate in her care plan meetings. The resident was assessed as cognitively intact with a score of 13 on the Brief Interview for Mental Status. A staff member responsible for inviting participants to care plan meetings confirmed that she contacts family members but does not document these invitations and acknowledged that the resident had not been invited to her care plan meetings.
Failure to Identify and Document Bilateral Grab Bars as Restraints
Penalty
Summary
The facility failed to identify bilateral grab bars as a potential restraint for a resident and did not complete necessary procedures such as a risk assessment, obtaining consent, or implementing restraint monitoring. During observations, bilateral grab bars were noted on the resident's bed. An interview revealed that consent might have been given due to the resident's history of falling out of bed and sustaining bruises, as well as undergoing head scans due to falls. However, the resident's electronic medical record lacked documentation of a risk assessment, physician's order, or signed consent for the use of the grab bars. The resident was assessed as dependent for turning and repositioning, and staff indicated that the grab bars were not used as an assistive device but rather for hanging the call light and bed controls. The facility's restraint policy stated that restraints would not be used for convenience.
Pharmacist Fails to Monitor Psychotropic Medication Duration
Penalty
Summary
The facility failed to ensure that a licensed pharmacist conducted a proper monthly drug regimen review for a resident receiving as needed psychotropic medication. Specifically, the pharmacist did not monitor a resident who was receiving lorazepam for an excessive duration. The resident's Medication Administration Record (MAR) indicated that lorazepam was administered on two occasions, and the order for this medication had been in place for more than 14 days. During an interview, a staff member was unaware of the prolonged order and noted that the pharmacist had not addressed this issue with the medical provider. The facility's policy required the pharmacist to monitor psychotropic medication use and notify the physician when a review was due, which was not adhered to in this case.
Failure to Limit PRN Psychotropic Medication to 14 Days
Penalty
Summary
The facility failed to ensure that as-needed psychotropic medications were limited to 14 days unless there was provider documentation explaining the rationale for continuing the medication. This deficiency was identified for one resident who had an order for lorazepam, to be taken twice a day as needed for anxiety or shortness of breath. The resident's medication administration record (MAR) showed that lorazepam was administered on two occasions, but the order for the medication remained active beyond the 14-day limit without documented justification from a medical provider. During an interview, a staff member acknowledged being unaware of the ongoing order for as-needed lorazepam beyond the 14-day period. The responsibility for monitoring such orders was attributed to the medication nurse or care coordination nurse. Additionally, the facility's medication regimen reviews, conducted by the pharmacist, failed to identify the prolonged as-needed use of lorazepam, and there was no evidence that the pharmacist contacted the provider to address this issue. The facility's policy on psychotropic medications clearly stated that as-needed orders should be limited to 14 days and used only for specific, documented circumstances.
Inadequate Supervision Leads to Resident Elopement and Injury
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident, resulting in a fall with injury. The resident, who had a history of elopement and periods of confusion, managed to leave the facility without staff awareness. On the day of the incident, the resident was restless and attempted to access the elevator multiple times. Despite staff efforts to redirect him, he successfully exited the building by catching the main door before it latched, leading to a fall in the street where he sustained facial injuries. The resident had a history of elopement, often leaving for the hospital connected to the facility. Staff interviews revealed that the resident was known to be restless and had learned to disable the door alarm system. The facility's Roam Alert System, intended to prevent such incidents, was reportedly unreliable, and staff had become desensitized to its alarms. The resident's elopement risk was documented, but the facility did not foresee his ability to exit the building until the incident occurred. Interviews with staff indicated a lack of clear protocol for 1:1 supervision, which was left to the discretion of the nurse on shift. The resident's care plan acknowledged his elopement risk and included interventions such as a new wander guard system and offering non-alcoholic beers to address his restlessness. However, these measures were insufficient to prevent the elopement and subsequent injury.
Latest citations in Montana
A resident with a history of hematuria, renal failure, anemia, and recent blood transfusions was readmitted from the hospital with discharge instructions to pause apixaban, but the facility failed to obtain admission orders and did not clarify the incomplete anticoagulant order. The resident’s care plan did not address anticoagulant use or monitoring, and staff administered multiple doses of apixaban after readmission. Nursing notes documented blood in the nephrostomy drainage bag on two days without provider notification or intervention, followed by worsening weakness, poor intake, and hypoxia that led to hospital transfer. Hospital records showed the resident had gross hematuria, hypotension, respiratory distress, acute kidney injury, and a critically low Hgb requiring transfusion, and a late entry note acknowledged that the discharge order to hold apixaban had been overlooked.
A resident who was cognitively intact but dependent for bowel and bladder care and limited in ROM reported that a specific staff member repeatedly left call lights unanswered for extended periods, causing the resident to soil briefs and then be pressured to ambulate to the bathroom and sign refusal-of-care forms. A family member corroborated long call-light waits and rude interactions, and staff noted the resident became anxious and displayed behaviors when care was forgotten or incomplete. Despite verbal reports, emails, and documentation at a care conference describing long call-light waits, incontinence episodes, and refusal forms used at night, no grievance was filed and the alleged neglect was not reported or investigated. The resident also developed unaddressed skin issues on the heels, coccyx, and ears, and +2 pitting edema in both feet and ankles, with offloading devices found unused in the room and no related wound orders or documented weekly skin assessments.
Multiple residents experienced inadequate pressure ulcer and skin care when staff failed to perform timely and accurate skin assessments, obtain and follow wound care orders, and implement appropriate care plan and nutritional interventions. One resident admitted with multiple skin issues developed a large, foul-smelling coccyx ulcer that was not promptly evaluated, lacked early wound orders, and was not reflected in the care plan or consistently documented on the TAR. Another resident with a coccyx pressure injury and a spinal incision had delayed wound measurements, late dietitian notification, missed daily wound treatments, and late addition of protein supplementation to the care plan. A resident using oxygen had painful, reddened ears and heel/eschar issues that were not captured in admission documentation, lacked wound orders, and had no subsequent skin assessments recorded. A further resident with a coccyx pressure ulcer had conflicting MDS staging and "present on admission" coding, along with numerous days where ordered daily wound care was undocumented or absent. Staff interviews revealed inconsistent weekly skin checks, missed admission skin evaluations due to EHR changes, limited dietitian availability, and wound care being performed by staff without formal wound training, all contrary to the facility’s own skin integrity policy.
The facility failed to thoroughly investigate, monitor, and document multiple abuse allegations involving staff-to-resident and resident-to-resident incidents. In one case, a resident reported that a staff member blew marijuana vape smoke in his face, but there was no related nursing documentation or post-incident monitoring. In another case, a resident reported being hit by another resident, was found with a red mark on the head, and was sent to the ER, yet nursing notes for both residents lacked documentation of the incident and follow-up monitoring. In a third case, a cognitively impaired resident with developmental delay was found in another resident’s room while that resident’s hands were being removed from inside the resident’s pants and shirt, after which the resident complained of pain and was sent to the ER; again, nursing notes for both residents contained no documentation of the event or post-incident monitoring, and the investigator did not fully interview or obtain written statements from all involved as required by facility policy.
The facility failed to thoroughly investigate multiple allegations of abuse and neglect, including one resident’s report that a staff member was verbally demeaning and rushed her during oral care, and another resident’s report of inadequate ADL care with prolonged call light response times and being left in a soiled brief. A staff member admitted not reporting or investigating the latter allegation, and no related documentation was produced. In a separate incident, a resident alleged a CNA turned off the call light and refused requested personal care; the facility interviewed only the involved staff and did not interview other residents who might also have experienced call lights being turned off without care being provided, despite a witness stating this was a common practice by multiple staff. Additional requested interviews and information were not provided to surveyors.
Surveyors found that the facility failed to complete timely and comprehensive baseline care plans for three newly admitted residents. One resident with multiple serious conditions and a coccyx wound had no baseline care plan addressing wound care, pain, or chronic conditions for several days after admission. Another resident with dysphagia, dementia, and documented skin issues on the buttocks, heels, and knee had a baseline care plan that did not identify pressure wounds or related treatments. A third post‑surgical resident with a Stage 3 pressure ulcer and a lumbar incision had a baseline care plan that omitted wound management and post‑operative pain control. A staff member reported that baseline care plans are only generated after the admission nursing assessment is completed and locked, and acknowledged they are not always completed on time.
A resident’s long-time friend, a former employee previously terminated over an abuse allegation, was barred from entering the facility when she attempted to visit, and was told law enforcement would be called if she returned. Another individual confirmed awareness of the restriction, expressed no concern about the friend abusing the resident, and stated that the facility did not offer supervised or common-area visits. A staff member reported that any former employee terminated for an abuse allegation was categorically prohibited from returning to the building, without considering the resident’s relationship with the visitor, despite a visitation policy stating residents have the right to receive visitors of their choice and allowing only limited or supervised access when abuse is suspected or found.
The facility failed to follow its grievance policy by not documenting or investigating a grievance request from a resident and family member alleging that a CNA ignored call lights for extended periods, failed to provide timely ADL care, forced ambulation to the bathroom at night, and pressured the resident to sign refusal-of-care forms, causing the resident to feel afraid and neglected. In a separate case, the facility did not adequately investigate or document a grievance from a dependent, mobility-impaired resident who reported that a male CNA was rough and refused to reposition his contracted legs for comfort, and the staff member assigned to the investigation did not identify the CNA involved or record her explanation of the situation on the grievance form.
A resident reported that a former staff member repeatedly left the call light unanswered for extended periods, did not provide needed ADL assistance, and encouraged the resident to sign refusal-of-care forms, resulting in the resident soiling briefs before being asked to ambulate to the restroom. Another staff member stated that no care concerns had been brought to their attention and acknowledged that the alleged abuse and neglect were not reported. When surveyors requested IDT notes, root cause analysis, reporting, and investigation documents related to the staff member and this resident, the facility was unable to provide any documentation, indicating the allegation was not timely reported to the State Survey Agency or investigated.
Surveyors found that several residents did not receive appropriate ADL and hygiene assistance or accurate documentation of those services. A dependent resident reported inconsistent help with meals, only sponge baths instead of showers for several weeks, lack of shaving, and prior grievances about staff not assisting with a urinal or repositioning his legs. Another cognitively intact resident, dependent for oral care and dressing, stated he was not offered mouthwash or a warm washcloth, and staff confirmed they had never offered mouthwash despite charting that personal hygiene was provided. A third resident, largely independent with self-care, reported that washcloths were not available unless requested, and no washcloths were seen in the room, while documentation showed staff performing most of her personal hygiene. These findings showed failures to offer basic hygiene items and to accurately document ADL care provided.
Failure to Clarify Anticoagulant Orders Leads to Unnecessary Drug Administration and Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s drug regimen was free from unnecessary drugs when nursing staff did not clarify and correctly implement anticoagulant orders upon the resident’s readmission. The resident had been hospitalized for hematuria, renal failure, and anemia, received multiple blood transfusions, and was discharged back to the facility with an After Visit Summary instructing that apixaban (an anticoagulant) be paused, with no restart date specified. Despite this, the facility’s admission documentation for the readmission date showed no admission orders, and the apixaban order was not clarified with the physician. The medication was restarted and administered after readmission, even though the hospital documentation indicated it was to be paused and later discontinued. Following readmission, the resident’s Medication Administration Record showed that seven doses of apixaban were given. The resident’s care plan, initiated on the readmission date, did not identify any problems, goals, or interventions related to anticoagulant use, safety, or monitoring for side effects. Nursing progress notes documented that the resident had a right-sided nephrostomy with yellow urine drainage on the day of readmission, and then documented blood in the nephrostomy drainage bag on two consecutive days. However, there was no documentation that the provider was notified about the hematuria or that any action was taken in response to this change. Subsequently, nursing notes described the resident as weak, not eating, unable to maintain a sitting position, and having low oxygen saturation that did not adequately improve with increased supplemental oxygen, leading to transfer to the emergency department. Hospital records from that visit showed the resident presented with hypoxia, hypotension, profound weakness, respiratory distress, gross hematuria, acute kidney injury, and a critically low hemoglobin of 6.9 g/dL, and that the resident had received an anticoagulant and required blood transfusions. A late entry nursing note at the facility later documented that the hospital discharge summary had been overlooked, the order to hold apixaban was not implemented, and the resident continued to receive apixaban until readmission to the hospital. The facility’s root cause analysis attributed the event to ambiguity in discharge communication and medication reconciliation workflow and noted that the apixaban order was incomplete and not clarified before administration.
Failure to Identify and Address Neglect, Call-Light Delays, and Skin Concerns
Penalty
Summary
The deficiency involves the facility’s failure to identify, report, and address neglect of care concerns for a cognitively intact resident who was dependent on staff for bowel and bladder care and had range of motion limitations in both upper and lower extremities. The resident reported that a specific staff member (NF7) repeatedly left his call light on for extended periods, often over 45 minutes and up to hours at night, resulting in him soiling his brief with bowel and bladder incontinence while waiting for assistance. When staff eventually responded, NF7 would attempt to have the resident ambulate to the restroom despite the resident already being incontinent, and would then encourage him to sign refusal of care forms when he declined. The resident described being upset, anxious, and irritable, and stated he usually “peed” and “soiled” his pants and developed skin issues from sitting so long without being cleaned. A family member (NF6) corroborated concerns about long call light response times, stating the resident’s call light was left on for over an hour, leading to incontinence episodes, and that NF7 spoke to the resident in a rude and angry manner. NF6 reported these concerns in person, by phone, and by email to facility staff, including staff members A and C. Staff member O reported that the resident had anxiety and behaviors that were exacerbated when staff forgot about him or failed to perform all required care. Despite these reports and the resident’s expressed fear and anxiety when NF7 was working, no staff member asked the resident if he felt safe or explored what had occurred on nights with or without NF7, and the alleged neglect was not reported or investigated by facility leadership. The resident also had unaddressed skin concerns and edema that were not properly identified or managed. Staff member B stated weekly skin assessments should have been done but that wound care staff were unaware of any ear or coccyx issues, and the physician orders lacked wound orders for the resident’s left heel. On assessment, staff member P observed eschar on the left heel that appeared to need debridement, redness and cracking on the right heel, pink coccyx, and reddened ears, with delayed capillary refill on one ear, as well as +2 pitting edema in both feet and ankles that had developed during the resident’s stay. Posey boots intended to offload the heels were found in the resident’s cabinet, and staff member P stated she had never seen them used on the resident. Additionally, at a care conference documented and signed by staff member C, the resident reported waiting 20–40 minutes for call lights at night, having accidents while waiting, and being made to sign refusal papers when he declined to go to the bathroom after already being wet. Despite this documentation of neglect-related concerns, no grievance was filed, and staff members B and C stated they were unaware of or did not report or investigate any alleged abuse or neglect for this resident.
Failure to Assess, Document, and Treat Pressure Ulcers and Related Skin Conditions
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain an effective system for pressure ulcer prevention, identification, assessment, and treatment for multiple residents. For one resident admitted with existing skin issues on the buttocks, both heels, and a right knee wound, nursing notes documented a silicone foam dressing on the coccyx that was saturated with foul-smelling brown-yellow drainage, and a non-stageable pressure ulcer with slough, black eschar, and a large reddened border. This was the first detailed description of the coccyx pressure ulcer, and there were no wound care orders in the chart at that time. A subsequent weekly skin evaluation described a large, deep coccyx wound with copious foul-smelling drainage and extensive slough and granulation tissue, but incorrectly listed that date as the first observation despite the wound being identified nine days earlier. Wounds on the left heel, right outer ankle, and right knee were not evaluated until several days after admission, and the right heel was never evaluated during the stay. The resident’s care plan did not identify pressure ulcers as a problem and contained no interventions for pressure ulcer care or nutrition to support wound healing, and the treatment administration record showed wound treatments were not ordered until several days after admission and were then not consistently documented as completed. Another resident was admitted with a coccyx area that was open and possibly caused by pressure, and a late entry note identified a Stage 3 pressure ulcer to the coccyx from admission. However, the nutrition evaluation form later indicated “no” to the presence of a pressure injury and instead listed “other skin condition,” even though coccyx wound care was ordered. The weekly skin evaluation documented the first observation and measurements of the coccyx wound two weeks after admission, and the dietitian was not notified until several days after that. The treatment record showed that daily wound care orders for both the coccyx pressure ulcer and a surgical spine incision were not carried out on at least two days. Nutritional interventions to support wound healing, including a protein supplement, were not added to the care plan until more than two weeks after the wound was identified. Staff interviews revealed that the dietitian was only present in the facility limited hours on two days per week, that residents admitted later in the week might not be assessed nutritionally until the following week, and that a fourteen-day delay in nutritional assessment, while allowed, was acknowledged as not best practice for residents with wounds. A third resident using oxygen reported pain behind both ears, and observation showed that oxygen tubing protectors had slid out of place, leaving the ears unprotected. The right ear was red where the tubing rested, and the left ear was very red with a whitish substance in the crease. Staff later described this resident’s skin as having eschar on the left heel that appeared to need debridement, a red and cracked right heel, a pink coccyx, and reddened ears, with the left ear showing slower capillary refill. The facility’s records contained no wound orders for the left heel, no skin assessments since the most recent readmission, and an admission nursing evaluation that documented the skin as warm, dry, intact, and without wounds. A fourth resident had a coccyx pressure ulcer that was present on admission and gradually decreasing in size according to wound assessments. However, MDS assessments contained inconsistent documentation: one assessment showed no unhealed pressure ulcers on admission, a later discharge assessment documented a Stage IV pressure ulcer present on admission, and a subsequent quarterly assessment documented a Stage III pressure ulcer not present on admission. Treatment administration records showed no coccyx wound treatment in one month, initiation of daily wound care late in the following month with at least one missed documented treatment, and in the next month, daily wound care orders with more than half of the scheduled treatments lacking documentation of completion. In the subsequent month, the TAR failed to show any wound care performed for the coccyx pressure ulcer. Staff interviews indicated that weekly skin checks were the facility practice but were not consistently completed, that nurses were not always coding or documenting wounds correctly, and that admission skin evaluations were sometimes not done due to issues with a new computer system. A staff member performing wound care on one resident’s coccyx reported having no formal wound training and described a wound bed fully covered with thick yellow-tan slough, which, according to the cited National Pressure Ulcer Advisory Panel guideline, could not be accurately staged, despite the facility’s practice of staging it as a Stage III pressure ulcer. The facility’s own Skin Integrity policy required that upon admission, the licensed nurse establish a plan of care based on risk factors or presence of wounds, conduct ongoing weekly full-body skin audits, document new skin impairments with detailed characteristics and measurements, record qualifying wounds on the weekly skin evaluation form, notify the medical provider and obtain treatment orders, notify the resident or representative, notify the registered dietitian, and implement and document appropriate care plan interventions. The findings across these residents showed that these policy steps were not consistently followed: admission and weekly skin evaluations were missed or delayed, wounds were not accurately or timely documented or staged, treatment orders were delayed or not consistently carried out, nutrition and care plan interventions for wound healing and prevention were not promptly implemented, and staff responsible for wound care sometimes lacked formal wound training.
Failure to Thoroughly Investigate and Document Multiple Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to complete thorough investigations, monitoring, and documentation for multiple abuse allegations. In one incident, a resident reported that a staff member blew marijuana vape smoke in his face. The staff member later admitted to vaping marijuana in the resident’s room. Despite this, the resident’s nursing progress notes for the period following the incident contained no documentation of the event or any post-incident monitoring, and the psychosocial impact assessment tool indicated that no ALERT charting had been done by nursing or social services. In a second incident, a resident sitting in a wheelchair by the nurse’s station told a staff member that another resident had hit him; assessment revealed a red mark on the resident’s head, and the resident was sent to the emergency room at the family’s request. However, nursing progress notes for both the alleged victim and the alleged aggressor for the days following the incident contained no documentation of the incident or any post-incident monitoring. The staff member responsible for the investigation stated that he relied on video footage and interviews with the two residents, but these interviews were only documented in the incident report, and no other staff or residents on shift were interviewed. In a third incident, staff found one resident in another resident’s room and observed the second resident removing his hands from inside the first resident’s pants and shirt; the first resident later stated, “It hurts down there,” and was sent to the emergency room. The first resident had diagnoses including unspecified symptoms involving cognitive functions and awareness, anxiety, depression, cerebral infarct, and was described as having a developmental delay with the mentality of an 8-year-old, while the second resident was cognitively intact based on a BIMS score of 14. Nursing progress notes for both residents for the days following the incident contained no documentation of the event or any post-incident monitoring. The staff member overseeing the investigation acknowledged that he did not document his post-incident checks, did not interview staff on shift or other residents, and no abuse education or protective measures for staff were documented, contrary to the facility’s abuse prevention policy that requires interviews with all involved, retrieval of written statements, and documentation of assessments and monitoring.
Failure to Thoroughly Investigate Allegations of Abuse and Neglect
Penalty
Summary
The deficiency involves the facility’s failure to fully investigate multiple allegations of abuse and neglect, including not identifying all potentially affected residents. One resident reported that a staff member (NF8) was “nasty and pushy” while assisting with oral care, telling her she should not take so long brushing her teeth because she only had eight teeth and making her hurry without giving her the time she needed. When the facility questioned NF8 about this incident, he resigned from his position. Review of the facility-reported incident showed no staff interviews were completed as part of the investigation, despite the importance of such interviews in understanding the incident and identifying root causes. Another resident reported inadequate ADL care by staff member NF7, including long call light response times and being left in a soiled brief for hours, and stated he had reported these concerns to facility staff. A staff member later stated they were unaware of any concerns from the resident or his family regarding NF7 and acknowledged they did not report or investigate the alleged abuse or neglect. When surveyors requested documentation such as interdisciplinary team notes, root cause analysis, reporting, and investigation related to concerns with NF7, none was provided. In a separate facility-reported incident, a resident alleged a CNA turned off the call light and refused to provide requested personal care. The facility interviewed only the staff involved that night and did not interview other residents who might have been affected by staff turning off call lights without providing care. A witness (NF5) reported that it was the facility’s usual practice to turn off call lights without providing help, that staff often told the resident they would return but did not always do so, and that multiple staff engaged in this behavior. Despite a request from surveyors, the facility did not provide additional resident interviews or information regarding this allegation by the end of the survey.
Failure to Complete Timely Baseline Care Plans for Wounds and Pain Management
Penalty
Summary
The deficiency involves the facility’s failure to complete timely and comprehensive baseline care plans that provided instructions for resident-centered care for three residents. One resident was admitted with multiple serious diagnoses, including acute kidney failure, anemia, atrial fibrillation, chronic respiratory failure, hypertension, a right femur fracture, morbid obesity, and muscle weakness. A nurse progress note documented a coccyx wound described as stage I open on the day of admission, yet no baseline care plan was initiated to direct staff in caring for the wound, managing pain, or addressing the resident’s chronic medical conditions. A care plan was not started until several days later, and when it was initiated, it only addressed advanced directives, oral/dental health problems, loneliness, and discharge planning, without including wound or pain management. Another resident was admitted with dysphagia, dementia, behaviors, a history of falls, and a urinary tract infection. Nursing progress notes documented skin issues on the buttocks, both heels, and the right knee, but the baseline care plan initiated the same day did not identify pressure wounds or any treatment for those wounds. A third resident, admitted after surgical repair of a lumbar 4 compression fracture, had a documented Stage 3 pressure ulcer and a lower back incision with intact staples on the admission nursing evaluation. However, the baseline care plan for this resident did not include wound management interventions or pain management for post-operative pain. During an interview, a staff member explained that the baseline care plan is triggered when the admitting nurse completes and locks the admission nursing assessment, and acknowledged that when assessments are not locked, baseline care plans are not completed and are not always done on time.
Failure to Honor Resident’s Right to Chosen Visitor
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to receive visitors of her choosing. A long-time friend of the resident, identified as NF1, reported that when she first attempted to visit the resident after the resident’s admission, staff member B escorted her out of the building and told her that law enforcement would be called if she returned. NF1 had previously been employed by the facility approximately four years earlier and had been terminated due to an allegation of abuse toward a resident. The facility did not allow her to visit the resident in any capacity. Another individual, NF2, stated he was aware that the facility was not allowing NF1 to visit the resident and that he knew about the prior abuse allegation but was not concerned about NF1 abusing the resident. NF2 stated he wanted NF1 to be allowed to visit and that the facility did not offer supervised visits or visits in a common area. He was hesitant to raise the visitation issue with the facility because he was concerned it might change how the resident was treated. Staff member B confirmed that any employee terminated due to an abuse allegation was not allowed to return to the building for any reason, and that this restriction was applied without considering the resident’s history with the visitor. The facility’s visitation policy stated residents have the right to receive visitors of their choice and that limitations may include denying or limiting access to individuals suspected of abuse until an investigation is completed or abuse is found, but the facility applied a blanket prohibition in this case.
Failure to Document and Investigate Resident Grievances Alleging Neglect and Inadequate Repositioning
Penalty
Summary
The deficiency involves the facility’s failure to follow its grievance policy and to ensure residents could voice grievances related to alleged abuse and neglect without discrimination or reprisal. One resident reported that a specific CNA (NF7) left his call light on for hours, did not assist with ADLs, and that this led to bowel and bladder incontinence while he waited for help at night. The resident stated that when the CNA finally responded, the CNA would force him to ambulate to the restroom instead of cleaning him in bed, and when the resident refused to ambulate, the CNA told him to sign a refusal of care form. The resident reported being afraid of this CNA and feeling neglected in his care, and he stated he reported these concerns to staff member C. An external email from NF6 to staff member C documented that the resident was afraid of NF7, described NF7’s statements about his job duties, and explicitly requested to file a grievance and have NF7 kept away from the resident. Additionally, a care conference note signed by staff member C documented the resident’s report of being made to sign refusal sheets at night and waiting 20–40 minutes for call lights to be answered. Despite this, staff member C, identified as the grievance official, stated there were no concerns brought forth from the resident or family regarding NF7, and no grievance was completed for this abuse/neglect allegation as required by the facility’s grievance policy. The deficiency also includes the facility’s failure to thoroughly investigate and document findings for another resident’s grievance regarding care. This resident, who had impaired mobility in both upper and lower extremities and was dependent for all ADLs except eating, reported that a night CNA was rough and refused to reposition his legs, and he stated he had complained to the facility but the issue continued. A written grievance from this resident documented that a male CNA would not readjust his legs for comfort. The grievance form’s investigative findings did not show any attempt to identify the specific night CNA involved or to clarify what care was being refused. Staff member E, who was responsible for investigating this grievance, could not recall details of the investigation and acknowledged she did not attempt to identify the accused CNA, characterizing the issue as a recurrent complaint and a miscommunication about repositioning due to the resident’s leg contractures. She stated she had encouraged the resident to be more specific about the repositioning requested but could not explain why this was not documented on the grievance form. The facility’s grievance policy required that grievances, including those involving abuse or neglect, be documented on a grievance form and investigated, but this was not done in accordance with policy for these residents’ complaints.
Failure to Timely Report Alleged Abuse and Neglect to State Agency
Penalty
Summary
The facility failed to timely report an allegation of abuse and neglect to the State Survey Agency involving one sampled resident, identified as resident #47. During an interview, resident #47 reported that a specific former staff member, NF7, would leave his call light on for hours, fail to assist with ADL care, and this lack of response resulted in the resident soiling his brief with bowel and bladder because he waited so long for help. The resident further stated that NF7 would encourage him to sign a refusal of care form and then expect him to ambulate to the restroom after he had already gone in his brief. In a separate interview, staff member B stated that no care concerns from the resident or family had been brought to their attention and acknowledged that they did not report the alleged abuse or neglect of care. A request by surveyors for documentation related to resident #47’s interdisciplinary team notes, any identified root causes, reporting, and investigation of concerns involving NF7 and resident #47 yielded no documentation by the end of the survey, demonstrating a lack of evidence that the allegation was reported or investigated as required.
Failure to Provide and Accurately Document ADL and Hygiene Assistance
Penalty
Summary
Surveyors identified that the facility failed to provide and accurately document assistance with activities of daily living (ADLs) for multiple residents. One resident, who was assessed on the MDS as dependent for all ADLs except eating (requiring only partial to moderate assistance with eating), reported not always receiving help with meals, having only sponge baths for several weeks instead of showers, and needing a shave while observed lying in bed in a hospital gown with several days of facial hair growth. This same resident had previously filed a grievance stating that a night nurse would not assist with use of a urinal despite his inability to do this himself, and that a male CNA would not readjust his legs for comfort. These findings showed a lack of consistent ADL assistance for a resident documented as dependent. Surveyors also found failures related to personal hygiene supplies and documentation for two other residents. One cognitively intact resident, dependent for oral hygiene and dressing, stated he had not been offered mouthwash or a warm washcloth to wash his face that day, and no mouthwash was present in his room; staff later confirmed they had never offered him mouthwash, despite documentation that personal hygiene was offered and that staff did most of the activity. Another resident, who stated she could wash her face, brush her teeth, and comb her hair mostly independently, reported that washcloths were never available unless she specifically asked staff, and on observation there were no washcloths in her room. Her EHR documentation showed staff did most of her personal hygiene activity, while staff later stated she was generally independent and that they had not been giving her a daily washcloth. These discrepancies demonstrated inaccurate ADL documentation and failure to routinely offer basic hygiene items such as washcloths and mouthwash.
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