St John's Lutheran Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Billings, Montana.
- Location
- 3940 Rimrock Rd, Billings, Montana 59102
- CMS Provider Number
- 275024
- Inspections on file
- 23
- Latest survey
- July 22, 2025
- Citations (last 12 mo.)
- 23
Citation history
Health deficiencies cited at St John's Lutheran Home during CMS and state inspections, most recent first.
Surveyors found that expired food items were not discarded, and perishable foods were not properly labeled or dated in several areas of the facility. Dietary staff did not have or follow written policies for food storage and handling, and dish sanitization water was not tested due to a lack of test strips, despite policy requirements for safe food handling and sanitation.
Staff did not consistently perform hand hygiene after assisting residents or while preparing and serving food, including serving coffee and feeding multiple residents without washing hands between contacts. Enhanced barrier precautions were not implemented for a resident with a chronic wound, as staff provided care without required PPE. Additionally, a staff member failed to follow glove use protocols during food preparation, using the same glove for multiple tasks and handling both food and soiled items.
The facility did not report findings of a resident-to-resident verbal altercation to the State Survey Agency within the required timeframe, and also failed to report allegations of resident-to-resident physical abuse within 24 hours as required by policy. Delays were attributed to unclear staff responsibilities and incidents occurring over a weekend, resulting in late notifications and documentation.
The facility did not make grievance forms readily available in common areas, failed to provide a secure method for anonymous written grievance submission, and did not ensure residents were informed about how to file grievances anonymously. A resident was unaware of the process, and staff confirmed forms were only available in an office, not accessible to residents.
A resident receiving oxygen therapy via nasal cannula at 2 L/min, as ordered by a medical provider, did not have this treatment included in their care plan. Staff confirmed the omission and were unsure why the care plan was not updated to reflect the resident's oxygen needs.
The facility did not update care plans to reflect the specific activity preferences and participation of two residents, nor did it include enhanced barrier precautions for a resident with an indwelling urinary catheter. Staff interviews and record reviews showed that individualized interventions and infection control measures were missing from the care plans, despite observations of resident needs and facility policy requirements.
Two residents experienced medication errors when staff delayed insulin administration until after a meal and incorrectly documented and omitted a scheduled dose of pantoprazole, resulting in a medication error rate above five percent.
The facility failed to meet residents' nutritional needs and follow planned menus. Staff did not review diet orders or menus, served meals not on the menu, and used improper serving methods. Inadequate meal preparation led to insufficient portions and lack of appropriate substitutes.
The facility failed to update care plans for three residents, leading to deficiencies in addressing their current needs. A resident dealing with grief lacked interventions for coping, another with frequent falls did not have a care plan including a camera for fall prevention, and a third resident's care plan was outdated, not reflecting a recent move. Staff acknowledged the need for timely updates.
The facility did not post daily nurse staffing information in four cottages housing 51 LTC residents. During a survey, it was observed that no postings were present. Interviews with staff revealed a lack of awareness about the absence of postings in the cottages, although staffing was posted on the rehabilitation unit.
The dietary department failed to provide residents with a nourishing diet and did not adhere to therapeutic diet requirements, leading to potential negative nutritional outcomes. Staff members did not review diet orders, resulting in improper serving sizes and failure to follow dietary guidelines. Interviews revealed a lack of awareness and adherence to dietary protocols, with staff failing to consult residents about meal preferences and not ensuring consistent nutrition.
The facility failed to provide sufficient and competent staff in food services, leading to delayed meal service and inadequate dietary management. Cooks were shared between cottages, causing meal delays, and staff lacked training on dietary changes and resident allergies. Observations showed understaffing led to missed cleaning duties and improper meal preparation, increasing risks for residents.
The facility failed to accommodate resident dietary needs in the [NAME] Cottage, as staff did not review diet orders or menus, leading to inappropriate meal service. Staff were unaware of special diets, and residents were not asked about meal preferences. Observations showed non-compliance with textural modifications, such as unminced sausage for residents on a minced and moist diet.
The facility's kitchens in the Powers, [NAME], and [NAME] Cottages were found to have significant sanitation issues, including dirty floors, improperly labeled and stored food, and poor hand hygiene practices by staff. Observations revealed black film on kitchen floors, leaking freezers, and sticky cupboard doors. Staff members were seen using contaminated gloves to handle food, and interviews highlighted concerns about cleanliness and a shortage of cooks affecting cleaning routines.
The facility failed to maintain proper infection control and PPE use during a COVID-19 outbreak. Staff were observed mishandling clean and dirty linens, improperly washing hands, and being unaware of outbreak status due to missing signage. A staff member was seen without a mask in an outbreak area.
A facility failed to assess two residents' ability to self-administer medications before leaving them unattended. A staff member left medications on a table and exited the dining area to take a phone call, without ensuring the residents had been assessed or had a physician's order for self-administration. Interviews confirmed the requirement for such assessments and orders, but reviews of the residents' records showed these were not in place.
A facility failed to accurately complete a resident's Quarterly MDS assessment. A staff member noted the resident often refused showers and personal care, and during one instance, observed redness in the resident's groin. Despite the nurse's recommendation for treatment, the resident refused care. The MDS assessment did not document these refusals, and the staff member responsible for the assessment could not explain the omission.
The facility failed to create timely baseline care plans for two residents. One resident, admitted for end-of-life care, had no care plan completed before passing away. Another resident with complex medical needs had a delayed and incomplete care plan, missing critical information on ADL assistance, seizure precautions, and speech therapy. Facility policy requires baseline care plans within 48 hours of admission.
A facility failed to consistently assess and document a resident's skin condition as part of preventative care. A staff member noticed redness in a resident's perineum during a shower and informed a nurse, who suggested treatment options that the resident refused. A review of records showed a lack of routine skin assessments, despite the facility's policy requiring weekly assessments.
A resident experienced repeated falls resulting in back injuries, and the facility failed to identify root causes or evaluate interventions. Despite frequent checks and camera monitoring, the care plan did not address falls individually or update interventions. The resident was removed from the Fall Management Program, and no new strategies were implemented, contrary to facility policy.
A resident dealing with grief and confusion after the loss of a spouse did not receive timely mental health services. Despite expressing feelings of missing his wife, the resident's care plan lacked interventions for grief or loneliness. Although a staff member provided some emotional support, there were no documented social services notes or evidence of grief counseling. Behavioral health counseling was ordered only after the resident's son reported forgetfulness.
The facility failed to limit PRN psychotropic medications to 14 days or document rationale for extended use for two residents. One resident continued using clonazepam PRN for insomnia without a stop date, despite a pharmacist's recommendation for adjustment. Another resident had lorazepam PRN for anxiety without a stop date, and the provider declined discontinuation despite no use in 30 days. A staff member noted awareness of the 14-day limit, but one physician did not always follow the policy.
A facility failed to obtain a signed consent for a pneumococcal vaccine for a resident who was confused and unable to consent. A staff member noted that the nurse should have contacted the resident's legal representative to discuss the vaccine's risks and benefits and to obtain consent. The facility's policy requires determining immunization status upon admission and offering vaccination to those without documentation, with vaccine type based on age and previous immunizations.
A facility failed to report an allegation of resident neglect within the required 24-hour timeframe. The incident occurred over a two-day period and was communicated to staff via email, but the report to the State Survey Agency was delayed. Staff member B acknowledged the delay, citing a lack of timely information despite being aware of the reporting requirements.
A resident's morning insulin was administered three hours late due to a delay in returning to their room after breakfast. The insulin, scheduled for 7:00 a.m., was given at 10:11 a.m. without re-checking the resident's blood sugar or notifying the physician about the delay.
Expired Food and Inadequate Sanitation Practices Identified
Penalty
Summary
Surveyors observed that the facility failed to dispose of expired food items and did not ensure proper labeling and dating of perishable foods in multiple cottages and the main storage room. Several food items, including coffee creamers, sliced cheese, ham, milk, prune juice cups, grape juice, chips, and fig newtons, were found to be expired or lacked open dates. Staff confirmed that expired items should be discarded and that all items should be dated, but these practices were not consistently followed. Additionally, staff reported the absence of dietary policies for food storage and handling, relying only on verbal instructions to follow Serve Safe guidance. Further observations revealed that dietary staff did not test the sanitizer water used for dishwashing, as there were no test strips available in any of the cottages. Staff stated that Ecolab managed the sanitizer units and checked them monthly, but no in-house testing was performed. Review of the facility's food safety policy indicated requirements for proper food handling, labeling, and dating, as well as the use of leftovers within three days, but these procedures were not being implemented as outlined.
Failure to Follow Hand Hygiene, Glove Use, and Enhanced Barrier Precautions
Penalty
Summary
Staff failed to perform appropriate hand hygiene after assisting residents and while preparing and serving food. Observations included a staff member assisting a resident to a dining table, touching the resident, and then serving coffee to multiple residents without performing hand hygiene between contacts. Another staff member was seen feeding two residents alternately without any hand hygiene during the meal, and a third staff member assisted three residents with their meals after moving a stool with bare hands, again without performing hand hygiene. The facility also failed to implement enhanced barrier precautions (EBP) for a resident with a chronic wound. The resident was observed with a wound dressing on her left foot, and staff assisted her with transfers and personal care without wearing an isolation gown, despite facility policy requiring EBP for residents with chronic wounds during high-contact care activities. Interviews revealed confusion among staff regarding which residents required EBP and when to use personal protective equipment (PPE). Additionally, staff did not follow proper glove use and hand hygiene protocols during food preparation. One staff member was observed wearing a glove on one hand while cooking, then using the same gloved hand to handle ready-to-eat food, touch various surfaces, and handle soiled items before removing the glove. Facility policies required hand washing before donning gloves, changing gloves as often as hands need to be washed, and not using the same gloves for multiple tasks, but these procedures were not followed.
Failure to Timely Report Abuse Allegations and Investigation Findings
Penalty
Summary
The facility failed to report the findings of a facility-reported incident to the State Survey Agency within the required timeframe for two residents involved in a verbal altercation. The incident occurred in a cottage dining room, where one resident was witnessed yelling at and insulting another. Although both residents were evaluated by staff and one was assessed for behavioral health treatment, the facility did not submit the investigation findings to the State Survey Agency until two days after the required deadline. Interviews with staff revealed confusion and lack of clear assignment regarding who was responsible for submitting follow-up reports, contributing to the delay. Additionally, the facility did not report allegations of resident-to-resident abuse to the State Survey Agency within 24 hours for another incident involving a physical altercation between two residents, resulting in a visible injury. The delay occurred because the incident happened on a weekend, and the responsible staff member did not review or report the event until the following Monday. The facility's own policy requires notification to the State Survey Agency within 24 hours and submission of investigation documentation within five business days, which was not followed in these cases.
Failure to Provide Anonymous Grievance Submission Process and Readily Available Forms
Penalty
Summary
The facility failed to develop and implement a policy and procedure that allowed residents to submit written grievances anonymously, did not provide residents with readily available grievance forms, and did not offer a secure receptacle for anonymous grievance submission. During an observation, no documentation was found in the common areas regarding how residents could file a grievance, and no grievance forms or secure submission boxes were present. Staff interviews confirmed that grievance forms were kept in a staff office and not accessible to residents in the common areas, and that there was no secure method for anonymous submission. A resident interviewed was unaware of the location of grievance forms or the process for submitting an anonymous grievance, stating she would typically inform staff of any issues. Review of the facility's grievance policy indicated that forms should be available adjacent to the Resident Rights posting and that grievances could be submitted anonymously via a compliance hotline, but these procedures were not observed in practice during the survey.
Failure to Include Oxygen Therapy in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident who required oxygen therapy. Observation revealed the resident was using a nasal cannula with an oxygen concentrator set at 2 liters per minute, as ordered by the medical provider. However, review of the resident's current care plan showed no focus, goal, or interventions related to oxygen therapy. During an interview, a staff member confirmed that the care plan had not been updated to include the resident's oxygen therapy, and was unsure why this omission occurred. The deficiency was identified through observation, interview, and record review, which confirmed that the resident's care plan did not address the ordered oxygen therapy, despite the resident actively receiving this treatment.
Failure to Update Care Plans for Activities and Infection Control
Penalty
Summary
The facility failed to ensure that care plans were updated to reflect resident-centered activity preferences and infection control measures for sampled residents. For one resident, observations and interviews revealed that although she participated in some activities, such as church services and family visits, her care plan did not document her specific preferences, the importance of church, or her limited participation in group activities. Staff interviews confirmed that changes in activity participation were not consistently documented in the care plan, and the care plan lacked individualized interventions such as one-to-one visits. Another resident, who was hard of hearing and rarely participated in group activities, also had a care plan that did not reflect her interests or preferences. Despite being dependent on staff for social needs and having recently moved cottages, her activity assessment was incomplete, and care team meeting notes were left blank regarding activities. The care plan failed to include her enjoyment of family visits and music or the use of one-to-one visits to address her needs. Additionally, a resident with an indwelling urinary catheter had enhanced barrier precaution signage on her door, but there was no personal protective equipment available for staff, and her care plan did not include interventions for enhanced barrier precautions. Staff interviews indicated that care plans were not updated to include these precautions, despite facility policy requiring such updates for residents with indwelling medical devices. The care plan only addressed the presence of the catheter and related self-care deficits, omitting necessary infection control interventions.
Medication Error Rate Exceeds Five Percent Due to Administration and Documentation Errors
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by a calculated error rate of 5.41 percent during the survey period. One incident involved a staff member delaying the administration of insulin to a resident until after the resident had finished breakfast, despite a physician's order specifying that insulin should be given before meals. In another case, a staff member administered acetaminophen to a resident during breakfast but incorrectly documented it as pantoprazole in the medication administration record (MAR), and did not administer the pantoprazole as scheduled before the resident ate, contrary to the physician's order for administration at 7:00 a.m. These actions resulted in medication errors for two residents out of a sample of twenty-five.
Failure to Meet Nutritional Needs and Follow Menus
Penalty
Summary
The facility failed to ensure that meals served to residents met their nutritional needs and that staff adhered to the planned menu or offered appropriate substitutes. During observations, staff members did not review residents' diet orders or the menu prior to meal service. Staff member N served bacon using her hands instead of the required scoop size and did not follow the menu, serving regular toast or pancakes instead of the planned banana french toast. Additionally, residents were not asked for their meal preferences. On another occasion, staff member P did not follow the menu and served plain scrambled eggs instead of the planned confetti eggs, cereal, hashbrowns, and toast. The cook ran out of hashbrowns, and no substitute was offered. Further observations revealed that staff member R did not have enough pancakes for all residents and failed to provide a minced meat substitute for breakfast, as required. Instead, she planned to provide double portions of meat at lunch. Eggs sterling was on the menu, but plain scrambled eggs were served, and there were not enough eggs for all plates. Staff member R redistributed eggs from already dished plates to ensure all residents received some, indicating a lack of preparation and adherence to dietary requirements.
Failure to Update Comprehensive Care Plans
Penalty
Summary
The facility failed to update the comprehensive care plans for three residents, leading to deficiencies in addressing their current needs. Resident #41, who was dealing with grief after the death of his wife, did not have a care plan that included interventions for coping with grief, despite staff awareness of his situation. Staff member G admitted to not updating the care plan, acknowledging a lack of diligence in this area. Resident #47, who experienced frequent falls and back pain, did not have a care plan that included the use of a camera for fall prevention, an intervention mentioned by staff member F. Staff member I emphasized the collective responsibility to ensure timely updates to care plans. Additionally, resident #3's care plan was outdated, still reflecting adjustment issues related to a move that occurred over a year ago. The care plan had not been revised to address a more recent move, which could have contributed to the resident's resistance to showers and incontinence care. Staff member C noted the resident's resistance might be due to being new to the cottage, indicating a need for updated care planning to reflect the resident's current situation.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post daily nurse staffing information in the four cottages housing 51 long-term care residents. This deficiency was identified during a survey conducted from August 12 to August 15, 2024. Observations during the survey revealed that no nurse staffing postings were present in any of the cottages. During an interview on August 14, 2024, at 8:17 a.m., a staff member was unable to identify where the nurse staffing information was posted in two of the cottages, although they mentioned that staffing was posted on the rehabilitation unit. Another staff member interviewed on August 15, 2024, at 11:55 a.m., was unaware that there were no staff postings in the cottages.
Dietary Department Fails to Meet Residents' Nutritional Needs
Penalty
Summary
The dietary department failed to provide residents with a nourishing diet and did not adhere to therapeutic diet requirements, leading to potential negative nutritional or health outcomes. Observations revealed that staff members did not review diet orders or therapeutic menus, resulting in improper serving sizes and failure to follow dietary guidelines. For instance, staff member N did not measure portions when serving bacon and used unwashed berries, while staff member P was unaware of special diets and did not ensure uniform serving sizes. Additionally, staff member P ran out of hash browns and did not provide substitutes, and staff member R did not have enough pancakes or eggs to meet the menu requirements. Interviews with staff members indicated a lack of awareness and adherence to dietary protocols. Staff member O admitted to not regularly checking on the cottages and expressed doubt that diets were being followed. Staff members also failed to consult residents about their meal preferences, and there was a general lack of communication and understanding regarding dietary needs. The report highlights multiple instances where dietary staff did not follow established procedures, leading to inconsistent and potentially inadequate nutrition for the residents.
Inadequate Staffing and Competency in Food Services
Penalty
Summary
The facility failed to ensure sufficient staffing with the necessary competencies and skillsets in the food and nutrition services, leading to delayed meal service and inadequate dietary management. During an entrance conference, staff members A and B revealed that cooks were shared between two cottages, resulting in meal preparation and service delays. An observation on 8/14/24 showed that the cook, staff member P, served breakfast 53 minutes late without assistance, contrary to the posted meal time. Staff member P, a CNA not typically involved in cooking, was unaware of dietary changes and resident allergies, indicating a lack of proper training and familiarity with the kitchen operations. Further observations revealed that the facility was understaffed, leading to missed cleaning duties and inadequate meal preparation. On 8/15/24, staff member R was observed with insufficient pancakes and failed to provide a minced meat substitute for breakfast, demonstrating a lack of knowledge about dietary requirements. Breakfast was again served late, highlighting the ongoing staffing and competency issues in the food and nutrition services, which increased the risk of negative outcomes for residents in the affected cottages.
Failure to Accommodate Resident Dietary Needs
Penalty
Summary
The facility failed to provide food that accommodated resident allergies and preferences in the [NAME] Cottage. Observations revealed that staff members did not review resident diet orders or menus prior to meal service. For instance, during a meal service, banana French toast was not served as per the menu, and minced bacon was served with syrup poured on top without considering resident preferences. Additionally, staff members were unaware of the number of special diets required, with one staff member expressing uncertainty about potential allergies to watermelon among residents. Further observations indicated that staff did not adhere to the required textural modifications for residents on specialized diets. For example, sausage was not minced for residents on a minced and moist diet, and no minced meat substitute was provided. Staff members admitted to not having time to prepare the food as required and planned to compensate by providing double portions at a later meal. The lack of adherence to dietary requirements and failure to consult residents about their meal preferences contributed to the deficiency.
Sanitation and Hygiene Deficiencies in Facility Kitchens
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchens of the Powers, [NAME], and [NAME] Cottages, as observed during a survey. The kitchen floors had a heavy accumulation of black film along the edges, and there was water leaking from a freezer door with a towel placed on the floor to absorb it. The freezer had a buildup of ice and rust-colored stains, and there were unlabeled and undated food items in both the freezer and refrigerator. The pantry refrigerator was dirty, with brown smears, red debris, and cheese-like shreds. Additionally, the cupboard doors were sticky, and there was no sanitizing solution for kitchen towels. The handles of the refrigerators and oven were soiled, and several spice containers were left open. Staff members were observed practicing poor hand hygiene and glove use. Staff member P was seen touching her hair and sticky cupboards with gloved hands and then handling food without changing gloves. She also used contaminated gloves to scoop food and handle resident plates. Staff member N similarly used the same pair of gloves to open cupboards, handle food, and serve residents, without changing gloves or washing hands. These practices were observed during breakfast service, where food items were also found to be improperly labeled and stored. Interviews with staff revealed concerns about sanitation and cleanliness in the kitchen. Staff member Q expressed concerns about the dirty vent cover and sprinkler head, while staff member T noted the vents were dirty and difficult to clean without a ladder. Staff member O, who visited the cottages weekly, was unaware of the freezer issues. The facility was experiencing a shortage of cooks, leading to missed cleaning tasks. The registered dietitian's audits highlighted unresolved issues, including dirty kitchen floors, lack of hand hygiene, and improperly labeled leftovers.
Infection Control and PPE Deficiencies During COVID-19 Outbreak
Penalty
Summary
The facility failed to ensure proper infection control practices and the use of appropriate personal protective equipment (PPE) during a COVID-19 outbreak. Observations revealed that a staff member, NF4, was seen carrying clean towels against her uniform and transporting dirty linens uncovered, placing them on the floor near the washing machine. Another staff member, R, was observed washing her hands but turning off the faucet with wet hands before drying them and proceeding with breakfast service. Additionally, during an interview, it was disclosed that the [NAME] Cottage was in outbreak status due to a positive COVID-19 test by a staff member. However, staff member E was seen changing a lightbulb without wearing a mask and was unaware of the outbreak status due to the absence of signage at the employee entrance. Staff member C acknowledged the lack of outbreak signage and stated she would address it immediately.
Failure to Assess Residents' Ability to Self-Administer Medications
Penalty
Summary
The facility failed to ensure that residents were assessed for their ability to self-administer medications before being left unattended while taking medications. During an observation, a staff member left medications for two residents on a table in the dining room and then left the area to take a phone call, leaving the residents unattended. This action occurred without any other nursing staff present to observe the residents taking their medications. Interviews with staff revealed that there was a requirement for an assessment of the resident's ability to safely self-administer medications and a physician's order permitting self-administration. However, reviews of the electronic health records for the two residents involved showed no such assessments or physician's orders. This oversight indicates a failure to adhere to the necessary protocols for medication administration in the facility.
Failure to Accurately Complete Resident Assessment
Penalty
Summary
The facility failed to accurately complete the Quarterly resident assessment for one of the sampled residents. During an interview, a staff member reported that the resident often refused showers and personal care assistance, opting instead for a sponge bath. On one occasion, while assisting the resident with a shower, the staff member noticed redness in the resident's groin area and notified a nurse, who recommended treatment with nystatin powder or cream. However, the resident refused the recommended treatments. Despite these refusals, the Quarterly MDS assessment did not document any behaviors related to the rejection of care during the assessment period. Another staff member, responsible for the assessment, acknowledged awareness of the resident's regular refusal of care but could not explain why this behavior was not coded in the MDS. This oversight led to the deficiency in accurately completing the resident's assessment.
Failure to Implement Timely Baseline Care Plans
Penalty
Summary
The facility failed to develop and implement a baseline care plan for two residents within the required 48-hour timeframe after admission. For the first resident, who was admitted for a short end-of-life stay, no baseline care plan was created, and the resident passed away six days after admission. Staff acknowledged that the care plan was not completed, possibly due to the resident's short stay. The facility's policy mandates that baseline care plans be initiated within 48 hours of admission by the interdisciplinary team (IDT). For the second resident, who was admitted with multiple complex medical conditions including epilepsy, dysphagia, and a suprapubic catheter, the baseline care plan was initiated late and lacked critical information. The care plan did not address the resident's need for assistance with activities of daily living (ADLs), seizure precautions, or speech therapy, despite these being pertinent to the resident's condition. The facility's policy requires that initial care plans include the primary reason for admission and be completed comprehensively within 21 days.
Failure to Document Routine Skin Assessments
Penalty
Summary
The facility nursing staff failed to consistently assess and document the skin condition of a resident as part of preventative skin care measures. During an interview, a staff member revealed that while assisting a resident with a shower, they noticed redness in the resident's perineum and informed a nurse, who suggested treatment options. However, the resident refused the recommended treatments. A review of the resident's electronic health record from January to August showed a lack of routine skin assessments, with only a few notes regarding the resident's skin condition, including a wound on the chin and the red groin. The facility's Skin at Risk Program indicated that skin assessments should be performed weekly, but documentation did not reflect this practice.
Failure to Address and Prevent Repeated Falls
Penalty
Summary
The facility failed to adequately address and prevent repeated falls for a resident who experienced multiple falls, resulting in back injuries. The resident expressed reluctance to ask for help, which contributed to the falls. Despite the implementation of frequent checks and a camera monitoring system, the facility did not effectively monitor the resident, as evidenced by the lack of staff presence in the nurses' room to observe the camera feed. The resident's care plan, initiated in July 2024, did not identify the root causes of the falls or evaluate the effectiveness of existing interventions. The care plan grouped the falls together without addressing them individually or updating interventions based on specific incidents. Post-fall documentation for several incidents failed to identify specific causes or evaluate the effectiveness of interventions, and no new strategies were implemented to prevent future falls. The resident was removed from the Fall Management Program because the provider deemed the falls unavoidable, and staff did not attempt new interventions. The facility's policy required root cause analysis and intervention for each fall, but this was not followed. The Quality Assurance and Performance Improvement committee was responsible for ensuring high-risk residents were included in the Fall Management Program, but the resident was not reviewed by the fall IDT team.
Failure to Provide Mental Health Services for Grieving Resident
Penalty
Summary
The facility failed to provide necessary mental health services to a resident who was experiencing grief and confusion following the death of his spouse. The resident expressed feelings of missing his wife and confusion, indicating a need for mental health support. Despite the resident's family visiting and a staff member providing some emotional support, the resident's care plan was not updated to include interventions for grief or loneliness. Additionally, there were no documented social services notes or evidence of grief counseling provided to the resident. A staff member mentioned placing an order for behavioral health counseling only after the resident's son reported his father's forgetfulness. The lack of documentation and timely intervention contributed to the deficiency identified by the surveyors.
Failure to Limit PRN Psychotropic Medications to 14 Days
Penalty
Summary
The facility failed to ensure that as-needed (PRN) psychotropic medications were limited to 14 days or had documented rationale for extended use by the physician for two residents. For one resident, a pharmacist recommended alternatives to a sleep aid/antianxiety medication, but the physician ordered clonazepam PRN without a stop date. The resident used the medication almost nightly, and despite a pharmacist's recommendation to adjust the regimen and document the next evaluation timeframe, the resident continued on the medication without further documentation through the survey date. For another resident, lorazepam was ordered PRN for anxiety without a stop date, and the resident received it twice in one month. The pharmacy noted the medication had not been used in 30 days, but the provider declined discontinuation and planned to review it within 60 days. An interview with a staff member revealed that medical providers were aware of the 14-day limit for PRN medications, but one physician did not always adhere to the policy. The facility's policy required PRN orders for psychotropic drugs to be limited to 14 days unless the physician documented a rationale and duration for extended use.
Failure to Obtain Consent for Pneumococcal Vaccine
Penalty
Summary
The facility failed to obtain a signed consent for the administration of a pneumococcal vaccine for one of the sampled residents. The resident in question was confused and unable to consent to the administration of the vaccine. During an interview, a staff member indicated that the nurse should have followed up with the resident's legal representative to educate them on the risks and benefits of the pneumococcal vaccination and to obtain their consent or declination. The facility's policy requires that the pneumococcal immunization status of all residents be determined upon admission and that vaccination be offered to those who cannot provide documentation of previous vaccination status. The policy also states that the type of pneumococcal vaccine should be determined based on the resident's age and previous immunizations, following current CDC recommendations.
Failure to Timely Report Allegation of Resident Neglect
Penalty
Summary
The facility failed to report an allegation of resident neglect within the required 24-hour timeframe. The incident involved a staff member allegedly neglecting a resident, which occurred between July 27 and July 29, 2024. The allegation was communicated to staff members J and K via email on July 30, 2024. However, the initial report to the State Survey Agency was not submitted until August 1, 2024, exceeding the 24-hour reporting requirement. During an interview, staff member B acknowledged the delay, attributing it to not being informed of the allegation in a timely manner, despite being aware of the reporting timelines. The facility's policy mandates that the Department of Public Health and Human Services Certification Bureau be notified within 24 hours of such incidents.
Delayed Insulin Administration
Penalty
Summary
The facility failed to provide medications in a timely manner for one of the sampled residents, resulting in a deficiency. During an observation and interview, a staff member was found administering morning insulin to a resident three hours past the scheduled time. The insulin was supposed to be given at 7:00 a.m., but it was administered at 10:11 a.m. The delay occurred because the nurse waited for the resident to eat before giving the insulin, and the resident did not return to their room until after 10 a.m. Additionally, the resident's blood sugar was not re-checked before administering the insulin, and there was no documentation indicating that the physician was notified about the late administration.
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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