Sidney Health Center Extended Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Sidney, Montana.
- Location
- 104 14th Ave Nw, Sidney, Montana 59270
- CMS Provider Number
- 275121
- Inspections on file
- 19
- Latest survey
- December 4, 2025
- Citations (last 12 mo.)
- 18 (1 serious)
Citation history
Health deficiencies cited at Sidney Health Center Extended Care during CMS and state inspections, most recent first.
Multiple residents experienced falls resulting in injuries such as fractures and lacerations due to the facility's failure to implement an effective fall prevention program. Staff did not consistently complete required fall checklists, update care plans, or conduct thorough post-fall assessments. Communication about fall risk was inadequate, and staff training on fall prevention interventions was lacking, leading to repeated incidents and insufficient individualized interventions.
The facility did not submit required reports to the State Survey Agency within mandated timeframes for several incidents, including unwitnessed falls with injury and an incident of staff-to-resident abuse. In each case, reports were filed late despite prompt internal notifications and investigations, with staff unable to explain the delays or clarify reporting responsibilities.
The facility did not complete or document thorough investigations for multiple facility-reported events, including unwitnessed falls with injury and a resident-to-resident abuse incident. In each case, only the event submission to the State Survey Agency was available, with no formal investigation files maintained or provided to surveyors.
The facility did not update care plans for several residents after fall incidents, failing to add new interventions or address root causes as required. Multiple residents experienced falls with injuries, but care plans were not revised, event forms were incomplete, and root cause analyses were not performed. Staff interviews indicated unclear processes and communication gaps regarding care plan updates after falls.
Staff physically restrained a resident to administer an IM medication, violating the resident's right to be free from restraint. The staff did not follow the care plan's behavioral interventions, and there was no physician order to hold the resident during the procedure. The facility's investigation confirmed that staff actions contributed to the escalation of the resident's behaviors and substantiated the occurrence of abuse.
The facility failed to provide continuous oxygen to two residents, leading to hypoxic episodes. One resident with severe COPD was found unresponsive without oxygen in the tub room, and another was taken to the dining room without oxygen, resulting in low oxygen levels and seizure-like activity. A second resident on the dementia unit was also found without oxygen, with saturation at 88%. The facility's policy requires a physician's order for oxygen use, but these incidents show a lack of adherence to this standard.
The facility failed to maintain a full-time on-site Director of Nursing (DON), leading to inadequate oversight and negative outcomes in respiratory care for two residents. The interim DON worked on-site for two weeks and remotely for two weeks, resulting in insufficient oxygen saturations due to lack of adherence to professional standards and physician orders.
A resident with dementia was found with bruises of unknown origin, and the facility failed to investigate thoroughly or report the incident to required officials. Despite staff noting the bruises were inconsistent with the facility's explanation, the investigation was limited and lacked proper documentation. The State Survey Agency was not notified, and the investigation did not adequately address the cause of the bruising.
A facility failed to implement a baseline care plan for a resident's oxygen use within 48 hours of admission, resulting in a hypoxic event. The resident had a long history of continuous oxygen use and was admitted with specific oxygen orders, which were not included in the initial care plan. The oversight was only corrected after the resident experienced a hypoxic event.
The facility failed to maintain consistent enhanced barrier precautions for two residents and lacked infection surveillance documentation for six months. Observations revealed missing precaution signs and PPE supplies, while interviews highlighted staff unawareness of precautionary measures. Additionally, the facility did not document infection surveillance or report communicable diseases as required, posing increased risk to residents.
A facility failed to update a comprehensive care plan for a resident using oxygen therapy, despite multiple MDS assessments indicating its necessity. The resident, diagnosed with acute and chronic respiratory failure, pneumonia, and pulmonary hypertension, was observed using oxygen therapy, yet the care plan lacked details on oxygen use, respiratory status, and necessary interventions. This oversight was a repeated failure from admission to the survey date.
The facility failed to update care plans for two residents, leading to deficiencies in their care. A resident who fell and complained of head pain did not have their care plan updated to address fall risks. Another resident with multiple sclerosis requested gait belts for leg support, but their care plan lacked documentation and assessment for the belts' use. Staff admitted to not reviewing or updating care plans, indicating a lack of oversight.
The facility failed to complete POLST forms for three residents, with missing dates, signatures, and contact information. Staff oversight was lacking, as there was no process to ensure forms were completed, and they were only discussed during care plan meetings.
A resident reported a grievance about a nurse's strong perfume odor, which was not documented or resolved by the facility. Despite a policy against strong scents, the issue was only addressed verbally, and staff were unsure of any follow-up actions, indicating a failure to adhere to the grievance policy.
A facility failed to identify and report irregularities in a resident's use of Xanax, a psychotropic medication, beyond the recommended 14-day period without proper documentation. The pharmacist incorrectly deemed the continued use acceptable, and a staff member indicated the physician intended to make it scheduled, but no documentation supported this change. The oversight highlights a failure in the facility's medication management process.
A facility failed to review or discontinue a resident's PRN Xanax after 14 days, as required by policy. The physician's progress note showed uncertainty about the resident's Xanax use, and despite requests, no documentation was provided to justify continued use. The facility's policy mandates PRN orders be limited to 14 days unless extended with documented rationale, which was not received. Staff noted that physician documentation was in a different system, contributing to the issue.
A facility failed to administer the recommended pneumococcal vaccine to a resident, as revealed during interviews and record reviews. The facility's policy was outdated, and staff were unclear about the immunization process. The resident had not received the necessary vaccine dose according to CDC guidelines, and there was no documentation of consent or declination for the vaccine.
Failure to Implement Effective Fall Prevention Program and Inadequate Post-Fall Response
Penalty
Summary
The facility failed to implement and maintain an effective fall prevention program, as evidenced by multiple incidents involving residents who experienced falls resulting in injuries, including fractures and lacerations. In several cases, staff did not complete required fall checklists or event forms, and there was a lack of timely and thorough nursing assessments following fall events. For example, one resident experienced a fall in the bathroom resulting in a rib fracture, but no fall checklist was completed, and there were no nursing progress notes documenting assessments of the resident's condition in the days following the incident. Another resident with a history of multiple falls, cognitive impairment, and high-risk medications experienced several falls, some resulting in head lacerations and bruising. The care plan for this resident was not updated to reflect new risks or interventions after each fall, and interventions such as fall or bed alarms were not considered or implemented. Staff interviews revealed inconsistent understanding and application of fall prevention protocols, and care plans often contained outdated or irrelevant interventions. Additionally, there was a lack of individualized interventions addressing specific risk factors such as incontinence and confusion. Further review showed that staff were not consistently trained or updated on fall prevention interventions, and communication regarding residents' fall risk was inadequate. Assignment sheets and room signage did not reliably indicate which residents were at high risk for falls. In some cases, falls were not investigated or discussed by the interdisciplinary team, and root cause analyses were not completed. Facility policies required comprehensive post-fall management and care plan updates, but these were not consistently followed, resulting in repeated falls and injuries among residents.
Failure to Timely Report Abuse, Neglect, or Injury Events
Penalty
Summary
The facility failed to submit timely reports to the State Survey Agency for multiple reportable events involving suspected abuse, neglect, or injury. In five separate cases, the facility did not meet the required two-hour reporting window for incidents involving serious bodily injury or suspicion of abuse. These included unwitnessed falls resulting in injuries such as a vertebral fracture, and an incident where a resident was held down by staff during medication administration, which led to the termination of two staff members for abuse. In each case, the initial or final reports were submitted late, sometimes by more than a day, despite internal notifications and initiation of investigations occurring promptly after the incidents. Interviews with staff revealed a lack of clarity regarding responsibility and procedures for timely reporting. Staff members acknowledged that reports should be filed as soon as possible, especially in cases of serious injury or abuse, but were unable to explain the delays. In some instances, the responsible staff member was not present in the facility at the time of the incident, and reporting was delayed until their return. The facility's investigation processes were noted to be in need of improvement, as evidenced by the repeated late submissions of required reports to the State Survey Agency.
Failure to Investigate and Document Facility-Reported Events
Penalty
Summary
The facility failed to conduct thorough investigations and maintain comprehensive documentation following facility-reported events for three residents. In one case, a resident experienced an unwitnessed fall resulting in a significant injury, including a fracture of the S5 vertebrae, and was treated in the ER. Despite the seriousness of the injury and the resident being an unreliable reporter, the facility did not provide an investigation file when requested by surveyors. In another instance, a resident was involved in a resident-to-resident abuse incident where they were pinched by another resident, but again, no investigation file was available for review. Additionally, a third resident sustained an unwitnessed fall with injury and was treated in the ER. Documentation revealed that no investigation was conducted for this incident, as the DON was not present in the facility at the time and did not initiate an investigation upon return. The only documentation available for these events was the submission of the event to the State Survey Agency, with no formal investigation files maintained. Interviews with staff confirmed the lack of investigation and documentation for these incidents.
Failure to Update Care Plans After Falls
Penalty
Summary
The facility failed to update and revise care plans for multiple residents following fall events, as required by policy and regulatory standards. For four residents, care plans were not updated to reflect new interventions or to address the root causes of falls, even after incidents that resulted in injuries. In several cases, fall safety event forms were not completed, and there was no documentation of root cause analyses or evaluation of existing interventions. For example, one resident experienced a fall resulting in a rib fracture while on anticoagulant medication, but the care plan was not updated to reflect this risk or to include new interventions. Another resident had an unwitnessed fall, but the care plan was not reviewed or revised, and the event remained open without a root cause analysis for over a month. Additionally, two other residents experienced multiple falls with injuries within a short time frame, yet their care plans showed no updates or new interventions in response to these incidents. Staff interviews revealed confusion regarding responsibility for updating care plans after falls, and there was a lack of clear communication about care plan changes to direct care staff. The facility's own fall prevention policy required care plan review and updates after any fall, but this process was not consistently followed, as evidenced by the lack of documentation and intervention updates in the residents' records.
Failure to Prevent Abuse and Use of Physical Restraint During Medication Administration
Penalty
Summary
Facility staff held a resident down to administer an intramuscular (IM) medication due to the resident's behaviors, which constituted a violation of the resident's right to be free from physical restraint. The staff's actions were not in accordance with the resident's care plan, as the behavioral interventions outlined in the care plan were not followed. Documentation indicated that staff attempted three interventions—offering food, assessing pain, and playing music—before administering the medication, but only the pain assessment was a care plan intervention, and there was no evidence that it resulted in an actual intervention such as administering pain medication. Additionally, offering food and music were not listed in the care plan as interventions. The facility's investigation substantiated that abuse occurred and found that staff interactions contributed to the escalation of the resident's behaviors. The resident's behaviors did not pose an immediate risk of harm to herself or others at the time of the incident. There was also no physician order authorizing staff to physically restrain the resident during medication administration. The incident was reported to the State Survey Agency, and the facility's investigation confirmed that the staff failed to follow established protocols and care plan interventions, resulting in the substantiated finding of abuse.
Failure to Provide Continuous Oxygen to Residents
Penalty
Summary
The facility failed to provide necessary respiratory care and services to two residents, leading to insufficient oxygen saturations. One resident, who had severe COPD and was oxygen-dependent, experienced a hypoxic episode in the tub room without her oxygen on. Staff member M applied oxygen and called the physician after the resident turned blue and was unresponsive. The resident's care plan did not initially include oxygen use, and it was only revised after the incident. Another incident involved the same resident being taken to the dining room without oxygen, resulting in low oxygen levels and seizure-like activity. The CNA responsible was new and reportedly not educated on which residents required oxygen. Another resident was found without oxygen on the dementia unit, with an oxygen saturation of 88%. Staff member N applied oxygen immediately, and the resident's levels returned to baseline. The facility's policy on oxygen administration requires a physician's order for its use, but the incidents indicate a failure to adhere to these standards, as both residents were found without their prescribed continuous oxygen.
Deficiency in Full-Time On-Site Director of Nursing
Penalty
Summary
The facility failed to ensure that a Director of Nursing (DON) was working full-time for 35 or more hours per week on-site, which increased the risk of negative outcomes for all residents due to the lack of onsite oversight. This deficiency was identified during a survey where harm was noted in the area of respiratory care and services, affecting two residents who experienced insufficient oxygen saturations. The facility had been unable to hire a permanent DON and had contracted an interim DON who worked on-site for two weeks and then remotely for two weeks. Observations during the survey confirmed the absence of the DON on several occasions, which contributed to the failure in providing necessary respiratory care and services in accordance with professional standards and physician orders.
Failure to Investigate and Report Bruising of Unknown Origin
Penalty
Summary
The facility failed to adequately respond to allegations of abuse concerning a resident who was found with bruises of unknown origin. The resident, who had dementia and required assistance for toileting, was noted to have dark purple and red bruising on her buttocks and thighs. Despite the bruising being reported to facility management, there was no evidence that the incident was thoroughly investigated or that it was reported to the required officials. The initial assessment by a staff member indicated that the bruising was higher than where a toilet seat would typically cause such marks, contradicting the facility's event report that suggested the bruises were from sitting down hard on the toilet. Interviews with staff revealed inconsistencies and a lack of thorough investigation into the cause of the bruising. One staff member mentioned that another staff member had found the resident on the floor, but this was not further investigated. Additionally, the State Survey Agency was not notified about the bruises, and the investigation only included interviews with four staff members, which were not dated to indicate when the investigation began. The lack of a comprehensive investigation and failure to report the incident to the appropriate authorities contributed to the deficiency.
Failure to Implement Baseline Care Plan for Oxygen Use
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a resident's oxygen use within 48 hours of admission, leading to a hypoxic event. The resident, who had been using oxygen continuously for many years prior to admission, was admitted with a physician's order for oxygen at 2-4 liters per minute via nasal cannula to maintain SaO2 at 90% or above. This order was later adjusted to titrate oxygen as needed to keep SaO2 at 88% or above, with the resident currently on 4 liters continuously. However, the baseline care plan did not include any problems, goals, or interventions for oxygen use. The omission was identified after the resident experienced a hypoxic event, and the oxygen usage was only added to the care plan post-incident. Staff acknowledged the oversight but indicated there was nothing that could be done about it after the fact.
Inconsistent Infection Control Practices and Documentation Lapses
Penalty
Summary
The facility failed to ensure consistent enhanced barrier precautions for two residents, which was identified through observations and interviews. Resident #37's door had a yellow isolation bag with gowns, gloves, and wipes, but lacked a precaution sign. Similarly, staff member M was unaware of the reason for an enhanced barrier precaution sign on resident #16's door, and no PPE supplies were found in the room or bathroom. These observations indicated a lack of proper communication and availability of necessary infection control supplies for residents under enhanced barrier precautions. Additionally, the facility did not provide documentation of infection surveillance and mandatory communicable disease reporting for six consecutive months. Staff member L, who had recently returned from medical leave, acknowledged the absence of surveillance tracking from March to August 2024. The facility's infection control program, which should include a system for prevention, identification, reporting, investigation, and control of infections, was not adequately maintained during this period. The facility's policies required healthcare providers to report confirmed or suspected cases of communicable diseases to the local health department. However, the lack of updated documentation and surveillance tracking suggests that these procedures were not followed. This deficiency in infection control practices posed an increased risk to the entire facility population.
Failure to Update Care Plan for Oxygen Therapy
Penalty
Summary
The facility failed to ensure a comprehensive person-centered care plan was created for a resident who utilized oxygen therapy. Despite the resident having three MDS assessments completed, all indicating the use of oxygen therapy, the care plan was never updated to reflect this need. This oversight was observed from the resident's admission and continued through multiple assessments, demonstrating a repeated pattern of failure. The resident's electronic medical record showed pertinent diagnoses, including acute and chronic respiratory failure with hypoxia, pneumonia, and pulmonary hypertension, yet these were not adequately addressed in the care plan. Observations and interviews confirmed the resident's ongoing use of oxygen therapy, with a nasal cannula connected to an oxygen concentrator set at 3 liters. However, the comprehensive care plan, revised shortly before the survey, lacked any mention of the resident's oxygen use, respiratory status, or necessary interventions. The care plan did not include problems, goals, or interventions related to oxygen use, nor did it provide guidance on oxygen saturation levels, flow rates, precautions, or equipment management. This deficiency was noted as a repeated failure from the time of the resident's admission to the date of the survey.
Failure to Update Care Plans for Fall Prevention and Gait Belt Usage
Penalty
Summary
The facility failed to review and revise the individualized care plans for two residents, leading to deficiencies in their care. Resident #10 experienced a fall on 11/30/23, resulting in head pain. The facility did not identify the root cause of the fall, and the care plan was not updated to address the risk of nighttime falls or toileting needs until 7/8/24. Staff member F admitted to not reviewing or updating the care plan after the fall, indicating a lack of oversight and stability in the care planning process. Resident #4, who has multiple sclerosis, requested the use of gait belts to hold her legs together while in a wheelchair due to muscle weakness. However, the care plan did not address the use of these gait belts, nor did it include a restraint assessment or guidelines for their use. Staff member I confirmed that the application of the gait belts was not documented in the care plan. The facility's policy requires comprehensive care plans to be periodically reviewed and revised, but this was not done for resident #4, resulting in a lack of documented interventions and assessments related to the gait belt usage.
Incomplete POLST Forms for Residents
Penalty
Summary
The facility failed to ensure that Provider Orders for Life-Sustaining Treatment (POLST) forms were properly completed for three residents. For one resident, the POLST form was not dated when signed by the resident's legal decision maker. Another resident's POLST form lacked the printed name, telephone number, and dates indicating when the form was prepared and signed. Similarly, a third resident's POLST form was missing the printed name, telephone number, and dates showing when the form was prepared and completed by the medical provider. Interviews with staff revealed a lack of oversight and process in ensuring POLST forms were completed. Staff member K, who was responsible for overseeing POLST forms and advance directives, admitted to not checking the forms when another staff member started filling them out. There was no established process to ensure the completion of POLST forms, and they were only discussed during individual resident care plan meetings. The facility's policy on advance directives indicated that residents should be informed of their rights to make medical decisions, but no specific POLST policy was provided during the survey.
Failure to Investigate and Resolve Resident Grievance on Strong Perfume Odor
Penalty
Summary
The facility failed to fully investigate and resolve a grievance reported by a resident regarding a strong perfume odor from a nurse, which was causing discomfort. The resident expressed concern about the potential impact on other residents with respiratory issues. This grievance was raised during a care planning meeting attended by staff members, but the resident did not receive any follow-up regarding the issue. Interviews with staff revealed that the facility had a policy against strong scents, allowing only lightly scented deodorant and laundry soap. Despite this policy, there was no written documentation of the grievance, and the issue was only addressed verbally. Staff members were unsure if any follow-up actions had been taken, indicating a failure to adhere to the facility's grievance policy, which requires prompt investigation and documentation of grievances.
Failure to Identify and Report Medication Irregularities
Penalty
Summary
The facility failed to ensure that the monthly drug regimen review process was effectively used to identify and report irregularities in medication use for a resident. Specifically, the pharmacist did not recognize a problem with the continued use of Xanax, a psychotropic medication, beyond the recommended 14-day period without proper documentation from the attending physician. The facility's policy on psychotropic medication management requires that PRN orders for such drugs be used only for a diagnosed specific condition and for a limited duration unless the physician provides a documented clinical rationale for extending the order. However, in this case, the pharmacist incorrectly deemed the continued use of Xanax acceptable, stating that it was not an antipsychotic and thus could be used beyond 14 days. The deficiency was further highlighted during an interview with a staff member responsible for tracking psychotropic drug use and notifying physicians of medication irregularities. The staff member indicated that the resident was allowed to continue using Xanax as needed because the physician intended to make it a scheduled medication. However, there was no documentation from the physician to support this change, and the as-needed Xanax had been refilled five times without the necessary documentation. This oversight indicates a failure in the facility's process to ensure compliance with its own policies and procedures regarding psychotropic medication management.
Failure to Review or Discontinue PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure that an as-needed psychotropic medication, Xanax, was reviewed or discontinued after 14 days for a resident. The resident's physician progress note indicated uncertainty about whether the resident had been using Xanax regularly or only as needed. Despite requests for medical provider documentation on the continued use of Xanax, no additional information was received by the end of the survey. The facility's policy on psychotropic medication management requires that PRN orders for psychotropic drugs be used only when necessary for a diagnosed condition and for a limited duration of 14 days unless extended with documented clinical rationale. However, the facility did not receive the necessary physician justification for the continued use of Xanax. Staff member D, responsible for tracking psychotropic drug use, noted that the physician documented notes in a different computer system than the one used by the extended care center, contributing to the lack of information.
Failure to Administer Pneumococcal Vaccine
Penalty
Summary
The facility failed to provide standard infection control practices by not ensuring that a resident received the recommended pneumococcal immunization. During interviews, it was revealed that the facility's pneumococcal policy was in the process of being updated, but the person responsible for this task had left the facility. Staff members were unclear about the exact process for maintaining immunization records, and it was noted that immunization status was only checked upon request. The facility had access to imMTrax for reviewing immunization statuses, but this was not routinely utilized. Resident #34's Preventive Health Care Report indicated that the resident was not current on her pneumococcal vaccination, having last received the PCV13 vaccine in 2018. According to CDC guidelines, the resident should have received a dose of PCV20 or PPSV23 at least one year after the PCV13 vaccine. The facility's policy required that residents or their legal representatives receive education about immunizations and have the opportunity to receive them unless contraindicated or refused. However, no documentation was provided for the resident's pneumococcal immunization consent or declination, indicating a lapse in following the facility's policy.
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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