Skyline Heights Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Billings, Montana.
- Location
- 1807 24th St W, Billings, Montana 59102
- CMS Provider Number
- 275020
- Inspections on file
- 33
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 21 (1 serious)
Citation history
Health deficiencies cited at Skyline Heights Nursing And Rehabilitation during CMS and state inspections, most recent first.
Two residents were not adequately informed or educated when their incontinence products were changed to smaller, reusable liners. Both expressed frustration and increased accidents, and staff could not provide documentation of individualized education or explanations regarding the change.
A resident experienced an unwitnessed fall with injury, and the facility failed to submit the investigation findings to the State Survey Agency within the required five-day period. The staff member responsible for reporting was filling in for another and was not educated on the reporting requirements, resulting in a two-day delay.
The facility did not update the comprehensive care plans for two residents after changing their incontinence products from disposable to reusable liners. Both residents expressed dissatisfaction with the new products, reporting increased accidents, but their care plans were not revised to reflect the new interventions, education provided, or the residents' concerns.
A resident with diabetes and neuropathy developed a foot ulcer that was not properly identified, documented, or treated by facility staff despite physician identification and a history of toe wounds. Weekly skin assessments failed to note the wound, prescribed treatments were not administered as ordered, and communication with wound care providers was inadequate. Delays and omissions in care led to the wound worsening, ultimately resulting in hospitalization and amputation of the resident's right great toe.
A resident with diabetes and neuropathy developed new foot wounds, but the facility did not update the care plan to reflect the resident's history of foot sores or provide preventative interventions for diabetic foot ulcers. The care plan was not revised to include the diagnosis or specific interventions for the ulcer until months after the issue was identified, leaving staff without clear guidance for care.
Nursing staff did not identify, assess, or document a diabetic foot ulcer for a resident, despite a physician's note and ongoing risk factors. Weekly skin checks failed to detect the ulcer, and prescribed wound care was not administered. Staff interviews revealed inconsistent assessment practices and a lack of formal wound care training. The resident was ultimately hospitalized and required amputation of the great toe due to lack of early identification and treatment.
Three newly admitted residents did not receive timely antibiotic and pain medications due to failures in the facility's pharmacy delivery, medication management, and communication systems. One resident with chronic pain and infection received no medications and left against medical advice, another missed IV antibiotics and was re-hospitalized, and a third experienced untreated pain and infection, leading to an ER transfer. Staff interviews confirmed delays, lack of medication availability, and inadequate documentation.
The facility failed to ensure that newly admitted residents received their prescribed medications, including pain management and antibiotics, due to missing or delayed medication orders and lack of medication availability. As a result, three residents did not receive essential medications, leading to unmanaged pain, missed antibiotic therapy, and transfers back to the hospital.
The facility failed to provide physician-ordered medications at the prescribed dose and frequency for several residents, leading to one resident discharging against medical advice, another being re-hospitalized due to missed IV antibiotics, and a third experiencing opioid withdrawal after not receiving pain medication. Staff interviews revealed ongoing pharmacy delays, lack of medication availability, and insufficient training on medication dispensing systems.
Several residents were served meals that did not match the facility's planned menu, with vegetables omitted and unapproved substitutions made. Some residents received food items they disliked or that were not listed on their meal tickets, and multiple residents reported the food was unpalatable. Staff interviews confirmed that a new cook was unfamiliar with the menu and that proper monitoring of meal service was lacking.
Nursing staff did not properly document or manage the care and removal of a PICC line for a resident, resulting in missed IV antibiotic doses, lack of documentation regarding the PICC line's presence and removal, and failure to follow established procedures. The resident experienced pain, pulled out the PICC line, and required emergency room care for pain management and line replacement.
The facility failed to provide adequate wound care and documentation for two residents, leading to deficiencies in pressure ulcer management. A resident's foot dressing was not changed as ordered, and her heel was not offloaded as required. Another resident developed a Stage III pressure ulcer, with inconsistent documentation and treatment. The facility did not adhere to physician orders, and staff interviews revealed confusion about care protocols.
The facility experienced significant staffing shortages, resulting in delayed response to call lights and inadequate personal care for residents. Multiple residents reported long wait times for assistance, leading to feelings of neglect and discomfort. The lack of sufficient staff also impacted the ability to provide regular bathing and personal care, with some residents receiving only one bath since admission. High turnover in nursing management and reliance on temporary staff further contributed to the challenges in maintaining quality care.
The facility failed to properly label and dispose of medications and medical supplies, with opened and undated vials and expired items found in various units. Staff interviews revealed inconsistencies in monitoring responsibilities, indicating a systemic issue in medication management.
The facility failed to maintain an effective QAPI system to address staffing, resident showers, and infection control issues. The QAPI plan was incomplete, lacking specific processes and time frames for improvement. Staff turnover in nursing management positions led to inconsistent management of staffing and infection control measures, disrupting the implementation of corrective actions.
The facility failed to follow a care plan by not placing a gel cushion on a resident's recliner, leading to a pressure ulcer. Additionally, another resident's care plan was not updated to include enhanced barrier precautions for an indwelling catheter. Staff confirmed the necessity of these interventions, but they were not implemented.
The facility failed to provide necessary dental services for three residents, resulting in discomfort and embarrassment. One resident had a missing tooth and another required a crown, while two residents had ill-fitting dentures. Despite their complaints, no dental appointments or referrals were documented.
The facility failed to adhere to physician-ordered therapeutic diets for several residents, including those on renal and carbohydrate-controlled diets. Residents reported being served inappropriate foods, such as high sugar and high carbohydrate items, and staff admitted to a lack of understanding and training on therapeutic diets.
The facility failed to consistently implement enhanced barrier precautions, as staff did not adhere to PPE protocols during wound and catheter care for several residents. Observations and interviews revealed that staff often used only gloves, neglecting gowns, despite facility policies requiring both for certain care activities. Additionally, staff lacked adequate training on proper PPE use, increasing infection risks.
A resident was found with multiple medications, including a controlled substance, left at her bedside, despite her evaluation only permitting self-administration of inhalers. Staff interviews revealed a lack of adherence to facility policies on medication management and self-administration, with no staff education provided on the matter.
A facility failed to create a comprehensive baseline care plan for a resident admitted after hospitalization for pneumonia. The resident, who began physical therapy soon after admission, had a care plan that did not address respiratory support and rehabilitation therapy services. This oversight was contrary to the facility's policy requiring the inclusion of physician orders and therapy services in baseline care plans.
Two residents experienced inadequate bathing and repositioning care, with one resident receiving only one shower since admission and no bed baths, despite being dependent on staff due to surgical wounds. Another resident, who preferred showers every two days, also received only one shower. Staff cited time constraints and workload issues as reasons for not completing all necessary tasks.
A resident's PICC line dressing was not changed as per physician orders, leading to the line being pulled out and replaced with an IV port. Staff admitted to being overwhelmed and unable to complete all tasks, resulting in the oversight. Facility guidelines for maintaining sterile dressings were not followed.
A resident with acute respiratory failure and airway obstruction did not receive prescribed nebulizer treatments in the facility. Despite having a physician's order for treatments every four hours, the resident reported worsening breathing and no treatments were administered or documented. Staff confirmed the absence of a nebulizer machine and lack of treatment documentation.
A facility failed to ensure a licensed pharmacist adequately addressed and documented the monthly medication regimen review for a resident on four psychotropic medications. Despite requests for an appropriate diagnosis for Olanzapine and consideration of gradual dose reduction, no changes were made. Staff acknowledged the pharmacy's failure to track medications and follow up on recommendations.
The facility failed to implement or document gradual dose reductions (GDR) for psychotropic medications for three residents. Despite care plans and medication reviews, no GDRs were attempted or documented as contraindicated. Staff interviews revealed issues with the pharmacy's tracking and recommendations, and the facility's policy on GDRs was not followed.
The facility failed to ensure residents' immunizations were up to date per CDC recommendations, affecting three residents. One resident had received two pneumococcal vaccines but required an additional one, while two others had no vaccines administered, despite refusals noted in facility documents. Staff interviews revealed inconsistencies in tracking and inputting immunizations, with reliance on residents' statements and lack of clinical oversight, leading to potential missed vaccinations.
A resident returning from the hospital for bronchitis experienced a five-day delay in starting prescribed medications due to the facility's failure to timely transcribe and initiate physician orders. Staff interviews revealed a lack of a clear process for handling new medication orders, compounded by inconsistent nurse staffing and management turnover. The facility's policy required timely communication and administration of medications, which was not effectively followed.
The facility failed to provide necessary ADL assistance for dependent residents, resulting in significant gaps in bathing and grooming. A resident reported not receiving a shower for over four weeks, despite being scheduled for twice-weekly showers. Another resident, dependent on staff for hygiene due to physical limitations, went 25 days without a shower. A third resident experienced long periods without bathing, feeling unclean due to staff being too busy. A staff member confirmed that some scheduled showers were missed due to workload.
A facility failed to supervise a resident with severe cognitive impairment during a medical appointment, leaving them unattended at a clinic. The resident, diagnosed with dementia and at risk for wandering, was transported by a facility employee but left unsupervised, contrary to their care plan. Staff interviews confirmed the lack of supervision, with one staff member acknowledging the need for supervision due to the resident's condition.
A resident with a known allergy to silicone catheters developed a rash after a suprapubic catheter replacement with a silicone catheter due to unavailable supplies. The nurse was unaware of the allergy and did not notify the medical provider immediately after the catheter change, leading to a delay in addressing the allergic reaction.
The facility failed to ensure food was served in a sanitary manner and did not practice proper hand hygiene while serving meals between residents. Staff members were observed eating and drinking in the tray line area and serving trays without performing hand hygiene between each meal delivery, despite having received training on these practices.
A resident identified with weight loss did not receive assistance with meals, as observed on multiple occasions. The resident's meal tray remained untouched while she was asleep, and staff were unaware of her dietary needs. Record reviews indicated the resident required meal setup and assistance, but these needs were not met.
Failure to Inform and Educate Residents on Incontinence Product Changes
Penalty
Summary
The facility failed to adequately inform and educate residents regarding a change in incontinence treatment and products. Two residents experienced a switch from their previous incontinence products to smaller, reusable liners without receiving a clear explanation or individualized education about the reasons for the change. One resident expressed frustration and sadness, noting increased accidents and dissatisfaction with the new products, while another questioned whether they could purchase their preferred products independently. Both residents reported that staff did not provide sufficient information about the change, and documentation confirming resident education was not available. Staff interviews revealed that the facility had discussed general information about skin breakdown and moisture management during a resident council meeting, but there was no evidence of individualized education or documentation provided to the affected residents. Review of care plans and physician orders indicated that residents had preferences for certain incontinence products, but the facility did not document any education or risk/benefit discussions related to the new products. The lack of communication and documentation led to resident frustration and a lack of understanding about their care changes.
Late Submission of Facility Reported Incident Findings
Penalty
Summary
The facility failed to submit the findings of a Facility Reported Incident involving a resident who suffered an unwitnessed fall with injury to the State Survey Agency within the required five-day deadline. The findings were submitted two days late. Staff interviews revealed that the staff member responsible for submitting the findings was filling in for another staff member who was out of state at the time of the incident. The substitute staff member acknowledged missing the deadline and submitted the findings as soon as she realized the requirement. Additionally, it was confirmed that no education had been provided to the substitute staff member regarding the reporting requirements related to this event. Facility policy requires the administrator to report the results of the investigation to government agencies within five working days of the incident.
Failure to Update Care Plans After Changes in Incontinence Products
Penalty
Summary
The facility failed to update the comprehensive care plans for two residents following changes in their incontinence care interventions. Both residents reported dissatisfaction with the new reusable liners provided, stating that these products were less effective and resulted in more frequent accidents. One resident indicated that they were no longer participating in care planning discussions, despite having previously done so. Staff confirmed that care plans should reflect all incontinence products tried and any changes made, but the documentation did not include the recent switch to reusable liners or the residents' feedback regarding their effectiveness. Record reviews showed that the care plans for both residents had not been revised to include updated interventions, education provided about the risks and benefits of the new incontinence products, or the facility's decision to change the products. The care plans only referenced previous interventions and did not document the residents' current experiences or the facility's recent changes in incontinence management. This lack of timely and accurate care plan updates failed to address the residents' needs and preferences as expressed during interviews.
Failure to Identify, Document, and Treat Diabetic Foot Ulcer Resulting in Amputation
Penalty
Summary
A facility failed to properly identify, assess, document, and treat a diabetic foot ulcer for a resident with a history of diabetes, neuropathy, and previous toe wounds. The physician initially identified a wound on the resident's right great toe in June, but the facility did not document or add this wound to the resident's diagnoses or care plan until several months later. Despite the resident's high risk for skin breakdown and a documented history of toe wounds, the care plan and interventions were not updated in a timely manner to address the new ulcer. Weekly skin assessments conducted by nursing staff repeatedly failed to identify or adequately document the right great toe wound, even after it was noted by the physician. There were inconsistencies and omissions in the administration of prescribed treatments, such as Mupirocin ointment, which was not administered as ordered in June and July. When the resident was sent to a wound care clinic, the facility failed to provide necessary documentation or communicate the specific concerns, resulting in the clinic being unaware of the wound and unable to provide targeted care. Additionally, there were delays in implementing wound care orders, with a nine-day gap between the order for Thera honey and PolyMem dressings and the start of treatment. Throughout the course of the resident's care, there was a lack of effective communication and follow-through among facility staff regarding the resident's wound status and treatment needs. Progress notes, skin assessments, and notifications to providers were incomplete or missing, and the resident's worsening condition was not promptly addressed. The failure to identify, monitor, and treat the diabetic ulcer led to the deterioration of the wound, resulting in hospitalization and amputation of the resident's right great toe.
Failure to Develop and Implement Comprehensive Care Plan for Diabetic Foot Ulcer
Penalty
Summary
The facility failed to ensure that a comprehensive care plan was developed and implemented to address a resident's diabetic foot ulcer and history of foot wounds. Documentation showed that the resident, who had a history of diabetes, neuropathy, and previous toe wounds, presented with new open and scabbed areas on the right toes. Despite these ongoing and new issues, the care plan did not reflect the resident's history of foot sores or provide specific preventative interventions for diabetic foot ulcers. The care plan was not updated to include the diagnosis of a diabetic ulcer until several months after the condition was identified, and interventions specific to the ulcer were only added after a significant delay. Interviews with staff revealed that nurses were responsible for updating care plans when new issues were identified, and that preventative measures should be included in the care plan. However, the care plan for this resident lacked documentation of the resident's history of foot problems and did not guide staff on preventative care for diabetic foot ulcers. Staff also indicated that changes to care plans were communicated during shift reports, but the care plan still failed to include necessary information to direct care for the resident's ongoing and current foot issues.
Failure to Identify and Manage Diabetic Foot Ulcer Leads to Amputation
Penalty
Summary
Facility staff failed to ensure that nurses and nurse aides possessed the necessary competencies and skills to identify, assess, document, and monitor a diabetic ulcer for one resident. Despite a physician's note documenting a diabetic ulcer on the resident's right great toe, weekly head-to-toe skin checks performed by facility staff throughout July failed to identify any skin issues. The first documentation of a skin alteration on the right great toe did not occur until early August, well after the physician's initial identification. Additionally, the medication administration record for July and August did not show evidence that staff administered the prescribed Mupirocin ointment as ordered by the physician. Interviews with staff revealed inconsistent practices and a lack of formal wound care training among nursing staff. One staff member admitted that skin issues might be missed depending on the thoroughness of the assessment and noted that formal wound care training was lacking, aside from wound vac training. Documentation and follow-up with the physician were also insufficient, as there was no evidence of ongoing monitoring or communication regarding the resident's diabetic foot ulcer after its initial identification. Ultimately, the resident required hospitalization and amputation of the right great toe after a wound care appointment, due to the facility's failure to provide necessary services for early identification, ongoing treatment, and preventative interventions.
Failure to Provide Timely Antibiotic and Pain Medication to Newly Admitted Residents
Penalty
Summary
The facility failed to ensure that newly admitted residents received necessary antibiotic and pain medications in a timely manner, resulting in neglect of care for three out of four recently admitted residents. One resident with a history of chronic pain, pneumonia, and sepsis did not receive any of his prescribed medications, including pain management and blood clot prevention, during his stay. This resident and his family expressed dissatisfaction with the lack of care, leading to his discharge against medical advice. Documentation showed that medication orders were entered into the electronic medical record, but no medications were administered, and there was a lack of nursing notes addressing the issue. Another resident, admitted for treatment of a septic shoulder and MRSA bacteremia, was supposed to receive IV antibiotics but missed two doses due to the facility's failure to provide the medication. The resident was not seen by staff until the following day and was subsequently sent back to the hospital for necessary antibiotic treatment. Staff interviews revealed that the antibiotics were not available, and the nurses on duty were not able to mix the medication, further delaying care. A third resident, admitted with cellulitis, abscesses, and narcotic dependence, did not receive ordered IV antibiotics or adequate pain management. The resident experienced significant pain and distress, ultimately pulling out her own PICC line and requiring transfer to the emergency room. Documentation and staff interviews indicated that medication orders were not entered in a timely manner, backup medication systems were not accessed appropriately, and communication with the pharmacy was insufficient. The resident also experienced opioid withdrawal symptoms due to missed pain medication doses. These deficiencies were linked to issues with the facility's pharmacy delivery program, oversight, and medication management systems.
Failure to Provide Timely and Necessary Medications to Newly Admitted Residents
Penalty
Summary
The facility failed to ensure that necessary medications were available and administered to newly admitted residents, resulting in significant medication errors for three out of four sampled residents. One resident was admitted with diagnoses including pneumonia, sepsis, and chronic pain, but did not receive any of his prescribed medications, including pain management and maintenance drugs, from admission to discharge. Nursing staff confirmed that no medications were entered into the electronic medication administration record, and the resident left the facility against medical advice due to not receiving medications. Another resident, admitted for treatment of a septic shoulder and bacteremia, was supposed to receive intravenous antibiotics as part of their care plan. However, the resident did not receive any doses of the ordered IV antibiotic, cefazolin, before being discharged back to the hospital. Staff interviews revealed that the antibiotics were not available and the resident was sent back to the hospital because the necessary medication could not be provided in a timely manner. A third resident, admitted with cellulitis, abscesses, and narcotic dependence, did not receive ordered IV antibiotics or pain medications upon admission. The medication administration record showed missed doses of vancomycin and linezolid due to lack of availability in the facility’s backup supply system. Staff reported delays in entering medication orders and issues with pharmacy communication, resulting in the resident experiencing pain, opioid withdrawal symptoms, and requiring transfer to the emergency room for further management.
Failure to Provide Timely Physician-Ordered Medications Resulting in Adverse Resident Outcomes
Penalty
Summary
The facility failed to provide physician-ordered medications at the prescribed dose and frequency for multiple residents, resulting in significant negative outcomes. One resident was admitted following hospitalization, but no medications were administered after admission due to the absence of available medications. The resident ultimately discharged against medical advice because the facility failed to administer any medications. Staff interviews confirmed that medications were not available and that there have been recurring issues with medications being delayed or stuck at other locations. Another resident, who required IV antibiotics for a septic shoulder and MRSA bacteremia, did not receive any doses of the prescribed antibiotic after admission. The medication administration record showed missed doses, and the resident was sent back to the hospital due to the inability to provide the necessary IV antibiotics. Staff interviews revealed ongoing pharmacy issues, lack of timely medication delivery, and that the nursing staff present were not able to mix the IV medications as required. A third resident did not receive any doses of IV Vancomycin as ordered and experienced opioid withdrawal symptoms due to the unavailability of hydrocodone. The resident became anxious and in pain, ultimately pulling out her own PICC line. Staff reported difficulties in obtaining the narcotic from the pharmacy, lack of training on the medication dispensing system, and delays in medication delivery due to pharmacy processes and external factors such as weather. Additional issues included medication storage errors and communication breakdowns between nursing and pharmacy.
Failure to Follow Menu and Provide Palatable, Appropriate Meals
Penalty
Summary
The facility failed to provide palatable food, follow the established menu, and ensure that residents received the foods specified on their meal tickets. During meal observations, several residents were served mashed potatoes with brown gravy, macaroni salad, and a meat or chicken salad, instead of the vegetable medley and grapes listed on the menu. Multiple residents did not receive a vegetable with their meal, and some expressed dissatisfaction with the taste of the food. One resident did not receive a vegetable and was served food items she did not like, as indicated on her meal ticket. Another resident was served a meal with overcooked pasta and a pale, mushy tomato meat sauce, despite her meal ticket indicating she did not like pasta or carrots. Staff interviews revealed that a new cook, unfamiliar with the facility's menu requirements, substituted mashed potatoes for vegetables without proper authorization or menu guidance. Staff acknowledged that the correct menu was not followed and that monitoring of meal service was inadequate. The diet extension menu did not list mashed potatoes and gravy as an approved substitute for any therapeutic diets or texture alterations, further indicating that the menu was not properly adhered to during meal service.
Failure to Document and Manage PICC Line Care and Removal
Penalty
Summary
Nursing staff failed to provide care for a resident with a peripherally inserted central catheter (PICC) line according to acceptable standards of practice. The resident's medication administration record did not indicate that IV antibiotics were being administered via the PICC line as ordered, and medications were not entered in a timely manner, resulting in missed doses. The resident subsequently pulled out her own PICC line after admission, but there was no documentation in the nursing progress notes regarding the presence of the PICC line or its removal by the resident. Interviews with staff revealed that the resident experienced pain and anxiety, and that the removal of the PICC line should have been documented in the electronic health record, but was not. Additionally, the facility failed to follow established procedures for PICC line removal, including assessment, notification of the physician, and documentation. The lack of documentation and failure to adhere to standards of practice led to the resident returning to the emergency room for pain management and PICC line replacement.
Deficiencies in Pressure Ulcer Management and Documentation
Penalty
Summary
The facility failed to ensure proper wound care and documentation for two residents, leading to deficiencies in pressure ulcer management. Resident #11's foot dressing was not changed as per physician orders, and the resident reported increased pain and worsening of her condition. Observations revealed that the dressing was wrapped tightly and had not been changed as scheduled. Additionally, the resident's heel was not offloaded using a Prevalon Boot as ordered. Staff interviews indicated uncertainty about the timeline of the resident's wounds and a lack of understanding of wound terminology, contributing to inadequate care. Resident #13 developed a Stage III pressure ulcer on her right medial buttock, which was not consistently documented or treated according to physician and hospice orders. The facility was responsible for changing the dressing five days a week, but there was no documentation of dressing changes for a 25-day period. Observations showed that the resident's recliner lacked a gel cushion for pressure relief, despite care plan instructions. Staff interviews revealed confusion about the frequency of dressing changes and the absence of necessary pressure-relieving equipment. The deficiencies in wound care and documentation for both residents highlight a failure to adhere to physician orders and care plans, resulting in inadequate pressure ulcer management. The lack of consistent documentation and appropriate interventions, such as offloading and pressure relief, contributed to the worsening of the residents' conditions. Staff interviews further indicated a lack of clarity and understanding regarding wound care protocols and responsibilities.
Staffing Shortages Lead to Delayed Care and Inadequate Personal Care
Penalty
Summary
The facility failed to ensure timely response to call lights and adequate personal care for residents, leading to significant dissatisfaction and discomfort among the residents. Multiple residents reported long wait times for call lights to be answered, with some waiting up to an hour and forty-five minutes. This delay in response left residents feeling neglected, unsafe, and in some cases, physically uncomfortable due to unmet needs such as assistance with toileting and transfers. The lack of timely response was attributed to insufficient staffing, with reports of only one CNA available for a large number of residents requiring mechanical lift transfers. In addition to the call light issues, the facility also failed to provide regular bathing and personal care for several residents. Residents reported having received only one bath since their admission, leading to feelings of uncleanliness and discomfort. The lack of adequate personal care was further exacerbated by staffing shortages, with staff members acknowledging that they were unable to complete all necessary tasks, including bathing and dressing changes, due to the high acuity of residents and insufficient staffing levels. Staff interviews revealed a high turnover rate in nursing management positions, contributing to the ongoing staffing challenges. The facility relied on temporary staff to fill gaps, which affected the consistency and quality of care provided. Staff members expressed frustration over the inability to meet residents' needs and the impact of staffing shortages on their ability to perform their duties effectively. The report highlights the facility's struggle to maintain adequate staffing levels and the resulting negative impact on resident care and satisfaction.
Improper Medication Labeling and Disposal
Penalty
Summary
The facility failed to ensure proper labeling and disposal of medications and medical supplies, which could negatively affect residents receiving expired medications or supplies. During observations, it was found that multiple vials of Tubersol intradermal injection solution were opened but not dated, and various medical supplies, including needles, blood collection tubes, and COVID test kits, were expired yet still available for use. Staff members were unclear about their responsibilities for monitoring and discarding expired items, indicating a lack of consistent oversight and management. Additionally, insulin pens and other medications were found opened and undated across different units, including Rimview and Copper Crest. Staff interviews revealed that there was an understanding that medications should be dated when opened, but this practice was not consistently followed. The lack of proper dating and disposal of medications and supplies suggests a systemic issue within the facility's medication management processes, potentially compromising resident safety.
Deficient QAPI System and Staffing Issues
Penalty
Summary
The facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) system to address performance improvement issues related to staffing, resident showers, and infection control. The QAPI plan provided by the facility was incomplete and lacked a documented process for maintaining identified concerns at acceptable levels of performance. The plan did not describe how the facility conducts required QAPI and Quality Assurance and Assessment (QAA) committee functions for identifying and correcting quality of care and quality of life deficiencies. The facility's QAPI documents were undated and only included slides with general goals, without specific processes or time frames for tracking and improving concerns. Interviews with staff revealed significant turnover in nursing management positions, which affected the facility's ability to manage staffing needs and training. The facility was in the process of hiring its sixth Director of Nursing (DON) within a year, leading to inconsistent management of nurse staffing issues. Additionally, the facility's infection control measures were not up to date due to the turnover of Assistant Directors of Nursing (ADONs) and DONs. The QAPI committee's efforts to address issues, such as a skin action plan related to showers, were disrupted by staff turnover, leading to incomplete implementation of corrective actions.
Failure to Implement Care Plans for Pressure Ulcer Prevention and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to the care plan for a resident by not placing a gel cushion on the recliner for pressure ulcer prevention. The resident, who had a history of sleeping in a recliner for fifteen to twenty years, developed a pressure ulcer on her buttocks. Despite the care plan indicating the need for a gel cushion, observations on multiple occasions revealed the absence of the cushion in the recliner. Interviews with staff confirmed the necessity of the gel cushion, yet it was not implemented, leading to the deficiency. Additionally, the facility did not update the care plan for another resident requiring enhanced barrier precautions due to the presence of an indwelling catheter for dialysis. The resident's care plan lacked interventions for enhanced barrier precautions, which are necessary for residents with wounds or indwelling medical devices. Staff acknowledged the oversight and were conducting an audit to ensure all applicable residents had the necessary precautions listed in their care plans.
Failure to Provide Dental Services for Residents
Penalty
Summary
The facility failed to provide necessary dental services for three residents, leading to discomfort and embarrassment for the individuals involved. Resident #36 expressed embarrassment and discomfort due to a missing upper right tooth and a left lower tooth that required a crown. Despite these issues, the resident's Minimum Data Set (MDS) did not reflect any broken or loosely fitting dentures or mouth pain. Resident #11 reported that her dentures did not fit correctly, causing discomfort and leading her to stop wearing them. This resident also experienced a weight loss of 3.82% over three months, which could be related to her dental issues. Resident #66 also reported that her dentures did not fit properly, making it difficult for her to chew. Despite these complaints, there were no dental appointments, notes, or referrals found for any of the three residents. Staff member A confirmed the absence of any dental service documentation for these residents, indicating a lack of follow-up on their dental needs.
Failure to Follow Physician-Ordered Therapeutic Diets
Penalty
Summary
The facility failed to ensure that physician-ordered therapeutic diets were followed for several residents. Resident #11, who was on a renal diet due to End Stage Renal Disease, reported being served tomatoes and high sugar foods, which are not suitable for her condition. Resident #15 mentioned that the diet served varied depending on the cook on duty. Resident #7, a diabetic, was served a breakfast high in carbohydrates, including oatmeal with brown sugar and a bagel, despite her meal ticket indicating a Carbohydrate Controlled (CCHO) diet. Similarly, residents #39, #36, and #66, all on CCHO diets, were served meals that included high carbohydrate items like hot dogs, french fries, and jello desserts. Resident #10, who required a No Added Salt (NAS) diet due to water retention issues, reported being served salty foods. Staff member M admitted to being unsure about the specifics of therapeutic diets such as CCHO and renal diets, and stated that the last training on therapeutic diets was six to eight months ago. Staff member K confirmed that therapeutic diets were not being followed, providing an example of diabetics being served regular syrup. These findings indicate a systemic issue in the facility's adherence to prescribed dietary requirements for residents.
Inconsistent Implementation of Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure consistent implementation of enhanced barrier precautions (EBPs) for several residents, leading to potential infection control issues. Resident #63, who had a below-the-knee amputation with open incision areas, reported that nurses only wore gloves during dressing changes, contrary to the facility's policy requiring gowns and gloves. An observation confirmed that a staff member did not follow proper PPE protocol during wound care, failing to sanitize hands and don gloves appropriately. Similarly, Resident #346, with dressings from a double amputation, noted that staff did not use the PPE provided in his room, and interviews with staff revealed a lack of adherence to EBP protocols. Additionally, residents #5 and #6, who required catheter care, reported inconsistent use of gowns by staff, with gloves being the primary protective measure used. The facility's policy, which mandates gown and glove use for wound care and high-contact activities, was not consistently followed. Interviews with staff indicated a lack of understanding and training regarding when and how to implement EBPs, with some staff unaware of the requirements or not having practiced donning and doffing PPE. This lack of consistent education and adherence to infection control protocols increased the risk of negative outcomes for the facility's population.
Failure to Properly Manage Self-Administration of Medications
Penalty
Summary
The facility failed to appropriately manage medications for a resident who was self-administering drugs. During an observation, it was noted that the resident had eight pills in a medication cup at her bedside, along with inhalers. The resident reported that staff would leave her medications in her room early in the morning. A review of the resident's Medication Administration Record (MAR) indicated that several medications, including a controlled substance, were administered to her that morning. However, the resident's Self Administration of Medication Evaluation only authorized her to self-administer inhalers, not other medications. Interviews with staff revealed a lack of understanding and adherence to the facility's policies regarding medication administration and self-administration. Staff members acknowledged that leaving medications, especially a narcotic, at the bedside was unacceptable. Despite this, there was no staff education on resident self-administration of medications. The facility's policy on controlled substances stated that only authorized personnel should have access to Schedule II drugs, yet this was not followed. The facility's policy on self-administration required medications to be stored securely, which was not the case for this resident.
Failure to Develop Comprehensive Baseline Care Plan
Penalty
Summary
The facility failed to develop and implement a baseline care plan that addressed the immediate care needs of a resident who was admitted after being hospitalized with pneumonia. The resident, who was transferred to the long-term care facility to regain strength and continue living independently, began physical therapy shortly after admission. However, the baseline care plan, created by the admitting nurse and intended to be updated by the interdisciplinary team, did not include necessary instructions for respiratory support and rehabilitation therapy services. This omission was identified during a review of the resident's electronic medical record and the facility's policy on baseline care plans, which mandates the inclusion of physician orders and therapy services to ensure effective, person-centered care.
Inadequate Bathing and Repositioning Care for Residents
Penalty
Summary
The facility staff failed to provide adequate bathing and repositioning care for two residents, leading to deficiencies in personal hygiene and skin care. Resident #346, who was dependent on staff for bathing and repositioning due to surgical wounds and skin breakdown, reported receiving only one shower since admission and no bed baths. Observations confirmed the resident's hair was oily and matted, and the resident expressed discomfort and dissatisfaction with the lack of personal cleanliness. Staff interviews revealed time constraints and workload issues, preventing them from completing all necessary tasks, including regular bathing and repositioning. Resident #347 also experienced inadequate bathing care, having received only one shower since admission despite a preference for showers every two days. The resident attempted self-cleaning but was discouraged from doing so by staff. Both residents' medical records indicated a preference for routine bathing, but their care plans lacked specific details on bathing preferences and frequency. The facility's failure to adhere to these preferences and provide necessary care contributed to the residents' dissatisfaction and potential health risks related to personal hygiene and skin integrity.
Failure to Change PICC Line Dressing as Ordered
Penalty
Summary
The facility nursing staff failed to provide appropriate treatment for a resident with a PICC line, as per physician orders. During observations, it was noted that the resident's PICC line bandage was improperly positioned and had not been changed according to the schedule. A staff member admitted to using gauze to stabilize the bandage, indicating that the dressing had not been changed by the staff. The resident's physician orders required the PICC line dressing to be changed every Monday during the day shift, but there was no documentation of dressing changes on the specified dates. The situation escalated when the resident's PICC line was pulled out, necessitating a visit to the Emergency Department where the line was removed and replaced with an IV port. The resident reported that the new IV port was stuck to his pajamas the following morning. Staff interviews revealed that they felt overwhelmed and unable to complete all expected tasks, which contributed to the oversight in care. The facility's guidelines for IV dressing changes emphasize the importance of maintaining sterile dressings and changing them if compromised, which was not adhered to in this case.
Failure to Provide Nebulizer Treatment for Resident with Respiratory Concerns
Penalty
Summary
The facility failed to provide necessary respiratory care for a resident with acute respiratory failure and intermittent acute airway obstruction. The resident, who had been receiving nebulizer treatments every four hours at home, expressed concerns about worsening breathing and the absence of nebulizer treatments since admission. Observations confirmed the lack of a nebulizer machine in the resident's room. Despite having a physician's order for nebulizer treatments documented in the Medication Administration Record (MAR), staff confirmed that no treatments had been administered, nor was there any documentation of the treatments being offered or refused in the resident's Electronic Health Record (EHR).
Inadequate Monthly Medication Review for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a licensed pharmacist adequately addressed and documented the monthly medication regimen review for a resident who was receiving four psychotropic medications. The resident's medication administration record for January 2025 showed prescriptions for Olanzapine, Clonazepam, Trazodone, and Paroxetine, with the Olanzapine lacking an appropriate diagnosis. Despite requests made in July and October 2024 to obtain an appropriate diagnosis for Olanzapine and to consider gradual dose reduction (GDR) for the medications, no dose reductions were attempted, and the diagnosis for Olanzapine remained unchanged. During an interview, staff members acknowledged the pharmacy's failure to track psychotropic medications and follow up on recommendations, indicating that the pharmacy did not thoroughly review the medical record to make appropriate suggestions for the monthly drug regimen review.
Failure to Implement Gradual Dose Reductions for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that gradual dose reductions (GDR) were implemented or documented as clinically contraindicated for residents receiving psychotropic medications. This deficiency was identified for three residents. For one resident, the care plan highlighted the need for GDR due to potential adverse effects of antipsychotics, yet no GDR was attempted or documented as contraindicated. The resident's medication administration record showed multiple psychotropic medications, but the pharmacist's progress note did not address changes made by the psychiatric provider. Another resident's medication administration record showed ongoing psychotropic medication use without GDR attempts, despite a history of failed GDRs and instructions for GDR to come from psychiatry. The third resident had been on several psychotropic medications for over seven months without any dose reductions attempted, and the pharmacy review failed to make appropriate recommendations. Interviews with staff revealed that the facility was aware of issues with the pharmacy's failure to track psychotropic medications and follow up on recommendations. The facility's policy required GDR attempts within the first year of a resident being on psychotropic medication unless clinically contraindicated, but this was not adhered to. Staff members acknowledged that the pharmacy did not thoroughly review medical records to make appropriate suggestions during monthly drug regimen reviews, contributing to the deficiency.
Deficiency in Tracking and Administering Pneumococcal Vaccines
Penalty
Summary
The facility failed to ensure that resident immunizations were up to date according to CDC recommendations for three of the forty sampled residents. Resident #10's electronic health record (EHR) indicated that they had received two pneumococcal vaccines, the Pneumococcal Polysaccharide Vaccine (PPSV23) and the Pneumococcal Conjugate Vaccine (PCV13), but an additional vaccine (PCV20 or PCV21) was recommended. Resident #336's EHR showed no pneumococcal vaccines were administered, although a facility document indicated a refusal with the comment 'up to date.' Similarly, resident #32's EHR showed no pneumococcal vaccines were administered, with a refusal noted in the facility document. Interviews with staff revealed inconsistencies and a lack of clarity in the process of tracking and inputting immunizations. Staff member B and N acknowledged that immunizations were tracked upon admission, but staff member O, who was responsible for tracking, admitted to having no clinical background and relied on residents' statements regarding their vaccination status. Staff member O also expressed uncertainty about whether a nurse had oversight of the immunization process, indicating a potential for missed immunizations. The facility's policy on pneumococcal vaccines, revised in March 2022, stated that residents should be assessed for vaccine eligibility prior to or upon admission, but the current practice did not align with this policy, leading to the identified deficiencies.
Delayed Initiation of Hospital Discharge Medications
Penalty
Summary
The facility failed to ensure that nursing staff transcribed and initiated physician orders for prescribed medications in a timely manner for a resident who returned from the hospital. The resident, who had been hospitalized for bronchitis, reported that the medications prescribed upon discharge were not started until a day or so after her return to the facility. Interviews with staff revealed that there was a delay in entering the physician discharge orders, which were not entered until several days after the resident's discharge from the hospital. This resulted in a five-day delay in starting the prescribed medications, including dexamethasone and doxycycline. The facility's process for handling new medication orders was found to be lacking, with staff indicating that there was no clear system in place for checking on new orders or ensuring they were received and initiated. The assistant director of nursing was previously responsible for reviewing discharge paperwork and clarifying medication orders with the pharmacy, but inconsistencies in nurse staffing and management turnover contributed to the issue. The facility's policy required nursing staff to communicate prescriber orders to the pharmacy and ensure timely administration of medications, but this was not effectively implemented, leading to the deficiency.
Failure to Provide Scheduled Bathing and Grooming for Dependent Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for dependent residents, specifically in the areas of bathing and grooming. Resident #7 reported not having received a shower for over four weeks, despite being scheduled for showers twice a week. The resident's ADL/Bathing record confirmed significant gaps between showers, with 47 days and 29 days without a shower on two separate occasions. Resident #7 expressed that staff were often too busy to provide the scheduled showers. Similarly, resident #5 had not received a shower in weeks and was highly dependent on staff for hygiene care due to upper and lower extremity limitations. The resident's records showed a 25-day gap without a shower. Resident #4 also experienced long periods without bathing, with 44 and 34 days between showers. This resident expressed feeling unclean and attributed the lack of showers to staff being busy. Staff member E confirmed that while most scheduled showers were completed, some were occasionally missed due to workload, as she was responsible for 15 residents during her shift.
Failure to Supervise Resident with Dementia at Medical Appointment
Penalty
Summary
The facility failed to provide adequate supervision for a resident with a dementia diagnosis, resulting in the resident being left unattended at a medical clinic. The resident, identified as having severe cognitive impairment with a Brief Interview for Mental Status score of five, was transported to an outside medical appointment by a facility employee. The resident's care plan indicated a risk for wandering and exit-seeking behaviors due to unspecified dementia and cognitive impairments. Despite these documented risks, the resident was left unsupervised at the medical office, as confirmed by interviews with facility staff. One staff member acknowledged that a staff member should have stayed with the resident due to their severe cognitive impairment, while another staff member stated that their role did not include staying with residents during appointments.
Inappropriate Catheter Use and Delayed Provider Notification
Penalty
Summary
The facility failed to provide necessary catheter supplies for a resident, leading to the use of inappropriate materials that caused an allergic reaction. A resident with a known allergy to silicone catheters experienced a rash after a suprapubic catheter replacement. The resident's medical record documented an allergy to silicone foley catheters, with a moderate severity reaction of blisters. Despite this, a silicone catheter was used on the resident when the suprapubic catheter became clogged and could not be flushed. The nurse who replaced the catheter was unaware of the resident's allergy and assumed silicone was hypoallergenic, leading to the use of the available silicone catheter. The facility also failed to notify the medical provider in a timely manner after the inappropriate catheter was inserted. The nurse did not contact the medical provider's office immediately after the catheter change but instead relayed the information to the incoming nurse during the shift report. The resident developed a rash, possibly related to the silicone catheter, and a new order was received for a catheter change and medication to address the allergic reaction. The delay in notifying the medical provider and the use of inappropriate catheter supplies contributed to the deficiency in care for the resident.
Failure to Maintain Sanitary Food Service and Hand Hygiene
Penalty
Summary
The facility failed to ensure food was served in a sanitary manner and did not practice proper hand hygiene while serving meals between residents. During an observation, a half-eaten grilled cheese sandwich belonging to a staff member was found on the resident tray line, and another staff member was seen drinking a personal drink in the tray line area while preparing resident dinner trays. Additionally, a staff member was observed serving trays to residents in their rooms without performing hand hygiene between each meal delivery. The staff member admitted to not knowing the requirement for hand hygiene between serving trays to residents. Interviews with staff members revealed that training had been provided on not eating or drinking while working the tray line and on hand hygiene when delivering and assisting residents with meals. The facility's policy on hand hygiene, revised in August 2019, mandates the use of an alcohol-based hand rub or soap and water before and after eating or handling food, and before and after assisting a resident with meals. Despite this policy and the training provided, the observed practices did not align with the facility's standards, leading to the identified deficiencies.
Failure to Assist Resident with Meals
Penalty
Summary
The facility failed to provide assistance with meals for a resident identified with weight loss. During multiple observations on 5/19/24, a meal tray was delivered to the resident and placed on her bedside table while she was asleep. No attempt was made by the staff to rouse the resident or assist her with the meal. The meal tray remained untouched for over an hour, and the staff collecting the trays did not notice or address the untouched meal. Interviews with staff revealed that the resident required assistance with meals and should be in the dining room for cueing, but the agency staff were unaware of these needs and did not have access to the resident's dietary information in the electronic medical record. Record reviews showed that the resident had been triggering for weight loss and required more cueing to focus on eating meals. The resident's care plan indicated the need for meal setup and assistance with eating, as well as supervision during meals to encourage intake. Despite these documented needs, the resident did not receive the necessary assistance, leading to the deficiency observed by the surveyors.
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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