Southwest Montana Veterans Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Butte, Montana.
- Location
- 65 Veterans Circle, Butte, Montana 59701
- CMS Provider Number
- 275156
- Inspections on file
- 14
- Latest survey
- June 23, 2025
- Citations (last 12 mo.)
- 25
Citation history
Health deficiencies cited at Southwest Montana Veterans Home during CMS and state inspections, most recent first.
The facility did not ensure that psychotropic medications were prescribed only for residents with clearly documented and diagnosed conditions, as two residents received antipsychotic medications for diagnoses not supported by their medical records. Additionally, a resident was maintained on multiple psychotropic medications without a physician-signed gradual dose reduction, despite pharmacist recommendations, and the required review process was not properly completed.
The facility did not ensure that PASRR documentation accurately reflected the mental health diagnoses of two residents receiving psychotropic medications for bipolar disorder, and failed to complete a required Level II PASRR for a resident newly diagnosed with Major Depressive Disorder. These omissions resulted in incomplete coordination of assessments and referrals for mental health services.
Several residents were found to have bed rails or similar devices in use without the required physician orders, informed consents, or signed statements of understanding. Staff interviews revealed confusion about terminology and inconsistent practices regarding documentation and assessment for bed rail use. Facility records and policies indicated requirements for consent and assessment, but these were not followed for the affected residents.
A resident with a history of PTSD and trauma from the Vietnam War did not have a care plan that specifically addressed his ongoing nightmares, unpleasant memories, and desire for isolation. The care plan only included general instructions about trauma triggers, lacking focused goals or interventions for his unique needs, despite the resident's continued psychological distress and avoidance of group activities.
A resident with cognitive and personal care needs did not consistently receive staff assistance with oral hygiene, as evidenced by persistent halitosis and staff observations of increased dependence, despite documentation indicating independence in oral care.
A resident with symptoms of a urinary tract infection had a positive urine culture, but antibiotic treatment was delayed for several days after results were available because the on-call provider could not access the results in the EHR or receive them by fax, resulting in the infection remaining untreated for a week.
A resident with a history of PTSD and significant trauma-related symptoms did not receive appropriate mental health treatment or trauma-informed interventions. The care plan lacked any focus or strategies for addressing PTSD, and the resident had not been referred to mental health professionals despite worsening symptoms.
Staff did not follow contact precautions for a resident with a physician order for Tinea Cruris, as staff members entered the room and assisted the resident without wearing required PPE such as gowns and gloves, despite posted signage and facility policy. Some staff were unaware of the reason for precautions or the correct procedures to follow.
Staff were unclear about proper disposal procedures for biohazardous waste, resulting in bags being left unboxed and stacked on the floor of a locked shed, with some boxes left open and the area emitting an unpleasant odor. The shed lacked a hand hygiene station, and staff reported inconsistent waste pickup and a shortage of boxes, leading to bags not always being secured or boxed nightly. These practices did not align with facility policy or CDC recommendations for medical waste storage.
A facility failed to respect a resident's right to self-determination by not allowing the POA to provide pureed food in squeeze packets, which followed the prescribed diet. Despite the food being appropriate and enjoyed by the resident, some staff refused it due to perceived dignity concerns. Interviews and observations showed the packaging was adult-focused, and several staff did not view it as a dignity issue, highlighting a deficiency in honoring the resident's preferences.
A facility failed to include a resident's bipolar disorder diagnosis in the admission PASARR assessment. The resident's PASARR only listed other medical conditions, despite later documentation in the MDS and psychiatric evaluations identifying bipolar disorder. The care plan also noted the risk for mood and behavior alterations related to bipolar disorder, and the resident was prescribed antipsychotic medication.
A facility failed to consistently manage the check-out process for residents, particularly those with cognitive impairments and a history of wandering. A resident left the facility without notifying staff, highlighting the lack of a reliable system to ensure supervision. Staff interviews and observations revealed inconsistencies in policy enforcement and unlocked doors, allowing unsupervised exits. The facility lacked a list of residents approved for self-check-out, complicating monitoring efforts.
Failure to Ensure Proper Use and Review of Psychotropic Medications
Penalty
Summary
The facility failed to ensure that psychotropic medications were used only for residents with specific, diagnosed, and documented conditions. In two cases, residents were prescribed antipsychotic medications (Quetiapine Fumarate and Risperdal) for diagnoses such as bipolar disorder, but review of their medical records and histories did not confirm the presence of these diagnoses. Staff interviews revealed uncertainty about the residents' diagnoses, and facility records, including histories and physicals, did not support the documented indications for the medications. Consent forms and medication orders listed diagnoses that were not substantiated in the residents' medical histories at the time of review. Additionally, the facility failed to obtain a physician-signed gradual dose reduction (GDR) for five psychotropic medications prescribed to another resident. Although the consultant pharmacist made recommendations for GDR, there was no evidence of physician review or signature on the relevant documentation. Staff interviews indicated that nurses were not involved in reviewing medications for possible dose reductions, and the process for obtaining physician approval for GDRs was not consistently followed, as evidenced by incomplete and unsigned forms.
Failure to Complete and Update PASRR for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure proper coordination and completion of the Pre-Admission Screening and Resident Review (PASRR) process for several residents with mental health diagnoses. For one resident, the PASRR Level I did not include a diagnosis of bipolar disorder, despite the resident receiving Quetiapine Fumarate for bipolar depression. Similarly, another resident's PASRR omitted a bipolar disorder diagnosis, even though the resident was prescribed Risperdal for this condition. In both cases, the PASRR documentation did not accurately reflect the residents' mental health conditions for which they were receiving psychotropic medications. Additionally, a third resident was diagnosed with Major Depressive Disorder after the initial Level I PASRR was completed, but a required Level II PASRR was not conducted following the new diagnosis. Although staff reported contacting the relevant entity and being told that a Level II PASRR was not needed, this communication was not documented, and the facility did not resubmit a Level I PASRR as required after the new mental health diagnosis was made.
Failure to Obtain Orders and Consents for Bed Rail Use
Penalty
Summary
The facility failed to obtain required physician orders, informed consents, and signed statements of understanding for the use of bed rails for five of thirteen sampled residents. Observations revealed that bed rails or similar devices were present on both sides of the beds for these residents, yet their electronic medical records did not contain the necessary documentation authorizing their use. Care plans referenced the use of bed canes, assist rails, or quarter rails to aid in bed mobility, repositioning, or transfers, but there was no evidence of proper assessment, consent, or physician order for these devices. Interviews with staff indicated confusion regarding the terminology and processes for bed rail use. Some staff members acknowledged that both physician orders and consents were required, while others were uncertain about the need for consents. Staff also reported inconsistent practices, such as sometimes obtaining paper consents or entering orders after assessments, but not consistently ensuring all required documentation was completed. There was also a lack of clarity among staff about the distinction between bed rails and bed canes, with some believing that consents were not needed for bed canes, despite their functional similarity to bed rails. A review of facility documents showed that there was a form intended for side rail utilization assessment and a policy requiring consent after presenting risks and benefits, but these were not consistently implemented. No additional documentation for physician orders, consents, or statements of understanding was provided for the affected residents during the survey. The lack of a standardized process and consistent terminology contributed to the failure to comply with requirements for the safe and authorized use of bed rails.
Failure to Develop Comprehensive Trauma-Informed Care Plan
Penalty
Summary
The facility failed to ensure that an updated and comprehensive care plan addressing trauma-informed care was in place for one resident with a history of significant trauma related to the Vietnam War. The resident experienced ongoing nightmares and unpleasant memories, and preferred isolation due to distress caused by discussions about the war. Review of the care plan revealed only general instructions regarding trauma triggers, such as noise reduction and maintaining routines, without specific focus, goals, or interventions tailored to the resident's PTSD or experiences as a prisoner of war. Interviews confirmed the resident's ongoing psychological distress and avoidance of social interaction due to his trauma history. The facility's documentation indicated that the interdisciplinary team is responsible for developing individualized care plans, but in this case, the care plan lacked detailed, measurable actions to address the resident's specific trauma-related needs.
Failure to Provide Consistent Oral Care Assistance
Penalty
Summary
A deficiency was identified when a resident who was dependent on staff for activities of daily living, including oral care, did not consistently receive assistance with oral hygiene. Observations and interviews revealed that the resident had noticeable halitosis during interactions, and staff acknowledged the resident's increased dependence, including needing help with dressing. Despite this, electronic health records documented the resident as independent in oral hygiene for 26 out of the past 30 days. The resident's medical record included diagnoses of a need for assistance with personal care and a cognitive communication deficit, indicating a requirement for staff support that was not consistently provided.
Delayed Treatment of Urinary Tract Infection Due to Lapse in Result Communication
Penalty
Summary
A resident experienced an elevated temperature and was suspected of having a urinary tract infection, prompting a provider to order a complete blood count and urine culture. The urine culture, finalized two days later, confirmed an infection and identified antibiotics to which the bacteria was sensitive. Despite these results, the resident was not started on antibiotic therapy until five days after the culture results were available and one week after the onset of symptoms. The delay occurred because the on-call provider was unable to access the results in the electronic health record system or receive them by fax, resulting in the infection going untreated for an extended period.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
A resident with a medical diagnosis of post-traumatic stress disorder (PTSD) was not provided with appropriate treatment and services to support his highest practicable mental well-being. The resident, a former prisoner of war, reported frequent nightmares, distressing memories, and avoidance of activities that reminded him of past trauma. He also described a history of violent dreams that affected his relationship with his wife, who no longer felt safe staying overnight with him. Despite these ongoing symptoms and an increase in the frequency of distress as indicated by recent trauma assessments, the resident had never been referred to or seen by a psychiatrist or psychologist for his PTSD. Review of the resident's care plan revealed that there was no focus, goal, or interventions addressing PTSD or trauma, nor were there strategies for staff to identify triggers or assist the resident if triggered. Previous trauma assessments showed a recent increase in the severity of symptoms, but this was not reflected in the care planning. The facility's own policy on trauma-informed care requires services that address the needs of trauma survivors, but this was not implemented for the resident in question.
Failure to Follow Contact Precautions for Resident with Fungal Infection
Penalty
Summary
Staff failed to follow contact precautions for a resident with a physician order for contact precautions due to Tinea Cruris, a contagious fungal infection. During observations, one staff member transferred the resident from a wheelchair to a recliner without wearing a gown or gloves, despite signage on the resident's door indicating Enhanced Barrier Precautions and Contact Precautions. The staff member also entered the resident's bathroom, touched the door handle, and handled the resident's water container without appropriate personal protective equipment (PPE). Upon leaving the room, the staff member performed hand hygiene but had already touched personal items and surfaces without PPE. Another staff member entered the resident's room to assist with lunch without donning a gown or gloves and expressed uncertainty about the reason for the contact precautions. Interviews with additional staff revealed a lack of awareness regarding the proper precautions required for the resident, although one staff member clarified that the resident was on contact precautions due to a fungal infection on his arms and was supposed to wear sleeves at all times. Review of facility policy confirmed the requirement for contact precautions for residents with infections transmissible by direct or indirect contact.
Improper Storage and Handling of Biohazardous Waste
Penalty
Summary
The facility failed to ensure proper storage and handling of biohazardous waste, as observed during multiple staff interviews and direct inspection of the waste storage area. Staff members were unclear about the correct disposal procedures for red biohazard bags, and it was noted that some biohazardous waste bags were not stored in boxes and were instead stacked on the floor of a locked shed. Additionally, some biohazard boxes were left open and not full, and the shed had an unpleasant odor upon opening. The shed did not have a designated area for staff to perform hand hygiene after handling biohazardous waste, and the storage area was observed to be full, with boxes placed toward the front of the shed. Staff also reported uncertainty regarding the frequency of waste pickup and admitted that biohazardous waste was not always secured or boxed nightly, with some bags left on the ground due to a shortage of boxes. Review of facility policies and CDC recommendations indicated that medical waste should be stored in labeled, leak-proof, puncture-resistant containers, kept covered, and protected from animals and pests. The facility's own policies required that medical waste be securely sealed, stored in rigid and leak-resistant containers, and kept covered at all times. However, these procedures were not consistently followed, as evidenced by the improper storage and handling practices observed and described by staff.
Facility Fails to Honor Resident's Food Preferences
Penalty
Summary
The facility failed to honor the resident's right to self-determination and communication by not allowing the Power of Attorney (POA) and decision-maker of a resident to make food preference requests that aligned with the physician's orders, dietary preferences, and swallowing precautions. The issue arose when the POA, identified as NF1, brought in pureed food in squeeze packets for the resident, which followed the prescribed diet. Despite the food being appropriate for the resident's dietary needs, some staff members refused to allow NF1 to provide these packets, citing concerns about dignity due to the packaging's appearance. However, the packaging was adult-focused, and several staff members did not view it as a dignity issue, noting that the resident enjoyed the food and it posed no choking risk. Interviews with staff members revealed differing opinions on the matter, with some staff not considering the squeeze packets as a dignity issue and acknowledging the resident's enjoyment and nutritional benefit from them. The resident's care plan indicated that the family was aware not to provide food in plastic pouches, yet the staff's actions contradicted the resident's right to self-determination and the POA's requests. Observations confirmed the presence of these food packets in the resident's room, and the packaging was deemed appropriate for adults, lacking any childlike colors. The facility's failure to accommodate the POA's requests and the resident's preferences led to the deficiency noted in the report.
Failure to Include Mental Health Diagnosis in PASARR
Penalty
Summary
The facility failed to include a mental health diagnosis in a resident's admission PASARR assessment. During an interview, a staff member acknowledged that the resident's diagnosis of bipolar disorder was not listed on the History and Physical (H&P) submitted for the PASARR at the time of admission in 2021. The PASARR, dated October 26, 2021, only listed chronic obstructive pulmonary disease, post-traumatic stress disorder, and dependence on supplemental oxygen as diagnoses. However, the resident's Quarterly MDS, with an Assessment Reference Date (ARD) of January 13, 2024, identified the resident as having a psychiatric illness: bipolar. Additionally, a psychiatric provider's initial evaluation from February 8, 2023, noted a background of Bipolar Unspecified. The resident's care plan, initiated on April 4, 2024, also indicated a risk for alterations in mood and behavior related to bipolar disorder, and the resident was prescribed antipsychotic medication.
Inadequate Supervision and Check-Out Process for Residents
Penalty
Summary
The facility failed to implement a consistent process for managing the check-out procedure for residents, particularly those with cognitive impairments and a history of wandering or elopement. This deficiency was highlighted by an incident involving a resident who left the facility on a scooter without notifying staff, despite having a documented history of wandering and cognitive impairment. The resident returned without incident, but the event underscored the lack of a reliable system to ensure residents at risk of elopement are adequately supervised when exiting the facility. Interviews with staff revealed inconsistencies in the enforcement of the sign-out policy, with some staff members indicating that residents do not always inform them when leaving. Observations showed that doors to certain cottages were unlocked, allowing residents to exit freely without supervision. Additionally, the facility did not maintain a list of residents approved to self-check-out, further complicating the ability to monitor and manage residents' movements effectively. The resident involved in the incident was on multiple medications, including narcotics, which could have impacted their decision-making abilities, yet there was no specific protocol in place to address such risks.
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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