Sweet Memorial Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Chinook, Montana.
- Location
- 125 Airport Rd, Chinook, Montana 59523
- CMS Provider Number
- 275127
- Inspections on file
- 22
- Latest survey
- January 29, 2026
- Citations (last 12 mo.)
- 23
Citation history
Health deficiencies cited at Sweet Memorial Nursing Home during CMS and state inspections, most recent first.
A deficiency was cited for failing to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, due to inadequate safeguards and oversight.
The facility did not report initial allegations or final summaries of abuse, neglect, or misappropriation of property to the State Survey Agency within required timeframes. Incidents included delayed reporting of suspected drug diversion, physical altercations between residents, and unexplained bruising, with staff confirming that notifications to authorities and final summaries were not made promptly.
The facility did not thoroughly investigate multiple alleged abuse incidents and unexplained bruising among residents. In several cases, altercations such as slapping, choking, and physical aggression were not followed by interviews, root cause analysis, or preventive interventions. Documentation was incomplete, and staff relied only on event reports without conducting further investigation.
The facility did not complete the care plan within 7 days of the comprehensive assessment, and the care plan was not prepared, reviewed, and revised by a team of health professionals as required.
The facility did not maintain a secure or detailed system for tracking controlled substances, allowing significant quantities of medications to go missing for several residents. A nurse continued to access and sign for narcotics for months after discrepancies were first identified, and the consultant pharmacist was not promptly involved in the investigation or monitoring. The facility's policy for immediate notification and reconciliation was not followed, leading to delayed reporting to authorities.
Two residents did not receive appropriate social services interventions after experiencing abuse from another resident, including one who felt isolated and vulnerable after being moved and another who was left upset and crying. Staff failed to assess or document the residents' psychosocial well-being following these incidents, and required depression assessments were not completed as scheduled.
The facility failed to investigate resident-to-resident altercations involving three residents. A staff member suspected an injury was due to an unwitnessed altercation, but the report did not explore this. In another case, two incidents of physical altercations were reported, lacking observations, interviews, and corrective actions. A staff member downplayed the incidents as mistreatment due to cognitive impairments.
The facility failed to oversee personal refrigerators in resident rooms, affecting three residents. Observations revealed missing temperature gauges and unlabeled food items, with one refrigerator having a thick ice buildup. Staff interviews showed unclear responsibility for refrigerator management, and the facility could not provide a relevant policy.
The facility failed to update care plans for several residents, including the discontinuation of a catheter, oxygen use, and bed rails. Additionally, a resident and their representative were not involved in the care planning process. Staff acknowledged the need for improvements in care planning.
The facility had a medication error rate of 8.16%, exceeding the acceptable limit of 5%. Errors included incorrect dosages of gabapentin and vitamin B-12 for two residents, and a failure to document held medications for another resident due to low blood pressure. These issues were identified during observations and interviews with staff.
A staff member failed to perform hand hygiene between administering medications to multiple residents. Despite touching residents' eating utensils and dishes, the staff member did not wash hands between residents, believing it unnecessary as she did not touch the pills directly. Upon interview, the staff member acknowledged the oversight.
A resident with severe cognitive impairment was struck twice by another resident who was having difficulty adjusting to the facility. The incidents were not classified as abuse by staff due to cognitive impairments and lack of injuries, but the facility failed to identify triggers or protect the resident from further abuse.
A facility failed to provide a baseline care plan to a resident or their representative. The resident reported not receiving any information about the care plan, and the representative confirmed the lack of communication. A review of the medical record showed no evidence of the care plan being provided, and no documentation was submitted upon request during the survey.
A facility failed to create a comprehensive care plan for a resident with broken and decayed teeth. Despite the resident's assessment indicating dental problems, the care plan lacked documentation or planning for dental services. A staff member confirmed that dental issues should be included in care planning, highlighting a lapse in the facility's process.
A resident experienced discomfort due to a poorly fitting wheelchair and the positioning of an oxygen tank. Despite informing CNAs, there was a lack of communication among staff, and the resident was not evaluated for proper wheelchair positioning during her physical therapy initial examination.
A resident experienced pain due to a callus on her left foot, which the facility failed to address appropriately. Despite a physician's order for a podiatry consult dated in September, the appointment was not scheduled. The resident reported ongoing pain, and an observation confirmed the presence of the callus. A staff member acknowledged that the consult had not been scheduled.
A facility failed to comply with the 14-day limit on as-needed antipsychotic medications for a resident with dementia, anxiety, and depression. The resident received olanzapine without the required physician evaluation and reordering every 14 days. Staff interviews revealed a misunderstanding of the policy and reliance on the EHR system to manage medication discontinuation, leading to a deficiency in medication administration practices.
The facility failed to discard expired Half and Half cartons in the walk-in cooler. Observations on consecutive days revealed cartons past their use by date, and a staff member confirmed that these should have been discarded, indicating a lapse in food safety protocols.
The facility failed to document and offer pneumococcal vaccines to two residents. One resident's history showed no record of receiving any pneumococcal vaccines, and the staff member responsible for immunizations could not provide information on the offering or declination of these vaccines. Another resident's history showed receipt of the Prevnar 13 vaccine but lacked documentation for Prevnar 20 or Pneumovax 23. The staff member was unable to explain the absence of these records.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report documents that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's protective measures and oversight. Specific details about the actions or inactions leading to the deficiency, as well as information about the residents involved or their conditions at the time, are not provided in the report. The deficiency centers on the lack of comprehensive protection for residents against abuse and neglect, as required by regulatory standards.
Failure to Timely Report Abuse, Neglect, and Misappropriation Incidents
Penalty
Summary
The facility failed to report initial allegations and final summaries of abuse, neglect, or misappropriation of property to the State Survey Agency within the timelines required by federal regulations for multiple residents. In one instance, a potential drug diversion involving resident medications was identified, but the facility delayed reporting the suspicion to the State Survey Agency and local law enforcement, choosing instead to complete an internal medication audit first. The initial report to the State Survey Agency was not made until several weeks after the investigation began, and law enforcement and the board of nursing were not contacted until even later. Additional incidents involved delayed reporting of physical altercations between residents and a case of unexplained bruising. In several cases, the initial reports or final summaries were submitted days after the events occurred, exceeding the required reporting timelines. Interviews with staff confirmed the delays and revealed a lack of immediate action in notifying authorities as required. The facility did not provide timely final summaries for several incidents, and in one case, no further investigation was conducted into the cause of a resident's bruising.
Failure to Investigate Alleged Abuse and Unexplained Injuries
Penalty
Summary
The facility failed to thoroughly investigate multiple alleged abuse incidents and unexplained injuries among residents. In one case, a resident was found with bruises of unknown origin on her foot, thigh, and calf, but there was no clear documentation in the medical record describing the bruises or their causes. Staff acknowledged that no further investigation was conducted beyond noting that the resident bruised easily, and no interventions or root cause analysis were completed. Additionally, several resident-to-resident altercations were not adequately investigated. These included incidents where one resident slapped, punched, or choked other residents, and another incident where a resident sprayed alcohol and sanitizer on another's face. The facility's documentation did not include interviews with involved parties, root cause analysis, or implementation of interventions to prevent recurrence. Progress notes often lacked details about the events, contributing factors, or steps taken to protect residents. Staff interviews revealed that the facility relied solely on event reports and risk management forms for investigations, with no further investigative actions taken.
Failure to Timely Develop and Review Care Plan
Penalty
Summary
The facility failed to develop the complete care plan within 7 days of the comprehensive assessment. The care plan was not prepared, reviewed, and revised by a team of health professionals as required. This deficiency was identified based on the review of facility records and documentation, which showed that the care planning process did not meet the specified timeline and team involvement requirements.
Failure to Secure and Monitor Controlled Substances Resulting in Drug Diversion
Penalty
Summary
The facility failed to maintain an adequate system for storing and monitoring controlled substances, resulting in missing medications for multiple residents. The investigation revealed that the facility used loose-leaf, unnumbered paper in a binder to track controlled drugs, which did not correspond to the medication cards and allowed for easy removal of both medication and records. This lack of a secure and detailed tracking system enabled discrepancies to go undetected, and several residents were found to be missing significant quantities of their prescribed medications, including Seroquel, Alprazolam, Mirtazapine, Tramadol, and Norco. The initial missing medication was identified when a resident ran out of Seroquel 14 days earlier than expected, and further review uncovered additional losses affecting other residents. Staff interviews indicated that a specific nurse was the common factor in the missing medication cases, yet this nurse continued to work and sign for narcotics for over two months after the first discrepancy was identified. The consultant pharmacist was not promptly informed of the diversion and did not participate in the investigation or monitor narcotics reconciliation logs. The facility's policy required immediate notification and monitoring in the event of discrepancies, but these procedures were not followed, and the local police and board of nursing were not contacted until months after the initial discovery of missing medications.
Failure to Provide Social Services After Abuse Incidents
Penalty
Summary
The facility failed to provide adequate medically-related social services to support the psychosocial well-being of two residents following incidents of abuse by another resident. One resident reported feeling isolated after being moved to a different area of the building due to repeated incidents involving another resident, including having hand sanitizer squirted in her eyes, which resulted in ongoing eye issues and feelings of vulnerability. Despite these events, there were no documented interventions or follow-up by social services to address her emotional well-being, and required assessments such as the PHQ-9 were not completed as scheduled. Another resident was observed crying and upset after being physically grabbed by the same resident, but staff attributed her distress to her usual behavior and did not assess or document her psychosocial or emotional health following the incident. Progress notes lacked information on interventions to prevent further abuse or to address the resident's emotional response to the event. These actions and omissions demonstrate a failure to ensure residents' highest practicable level of physical and psychosocial well-being through appropriate social services interventions.
Failure to Investigate Resident Altercations
Penalty
Summary
The facility failed to thoroughly investigate resident-to-resident altercations, alleged to be abuse, involving three residents. In one incident, a staff member reported an injury of unknown origin on a resident's forehead, suspecting it was not from a fall due to the resident's inability to get back into her wheelchair without assistance. The staff member believed the injury might have resulted from an unwitnessed altercation with her roommate, who was known to be aggressive. However, the facility's report did not explore this possibility or document the resident's room change for safety. In another case, two incidents of physical altercations between two residents were reported, where one resident was seen punching and hitting the other. The investigations lacked observations of the aggressor's interactions with others, interviews with residents and staff, and documentation of corrective actions to protect the victim and other vulnerable residents. A staff member involved in the investigation downplayed the incidents as mistreatment rather than abuse due to the cognitive impairments of the residents involved.
Lack of Oversight for Personal Refrigerators in Resident Rooms
Penalty
Summary
The facility failed to provide proper oversight for the use of personal refrigerators in residents' rooms, affecting three sampled residents. During observations, it was noted that the personal refrigerators lacked temperature gauges, which are necessary to ensure food is stored at safe temperatures. Additionally, there were multiple instances of food items being stored without labels or dates, and one refrigerator had a thick layer of ice built up inside and outside the freezer compartment. These deficiencies were observed in the personal refrigerators of three residents, indicating a lack of consistent management and oversight. Interviews with facility staff revealed a lack of clarity and responsibility regarding the management of personal refrigerators. A staff member from the housekeeping department indicated that the housekeeping supervisor was responsible for managing the refrigerators, but there was no clear protocol for when the supervisor was absent. Another staff member was unaware of how many residents had personal refrigerators or how they were managed for food safety. The facility was unable to provide a policy on personal refrigerators when requested, further highlighting the oversight issues.
Deficiencies in Care Plan Updates and Resident Involvement
Penalty
Summary
The facility failed to update and revise comprehensive care plans for several residents, leading to deficiencies in care documentation and planning. Resident #18's care plan did not reflect the discontinuation of a Foley catheter, despite a physician's order to begin bladder training and remove the catheter. Additionally, the care plan for resident #15 lacked details on the administration of oxygen, which was observed to be improperly used, and the resident experienced difficulty breathing without it. Furthermore, the care plans for residents #12, #18, and #27 did not document the use of bed rails or their intended purpose, indicating a lack of comprehensive care planning. The facility also failed to involve resident #20 or their representative in the care planning process. Resident #20 reported not being asked about their care plan, and their representative confirmed no communication from the facility regarding the plan of care. The electronic health record for resident #20 lacked documentation of their involvement in care planning, and no care plan meeting was held after the development of the comprehensive care plan. Staff member B acknowledged the need for updates and improvements in care plans, highlighting a gap in the facility's care planning process.
Medication Administration Errors and Documentation Issues
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a calculated error rate of 8.16%. This deficiency was observed in three residents. For one resident, a staff member incorrectly administered gabapentin by using a 1 ml syringe and filling it to the 0.1 ml line instead of the required 1 ml, leading to an underdose. The error was realized and corrected after the initial administration. Another resident was supposed to receive 5000 mcg of vitamin B-12 but was given only 500 mcg due to the staff member administering a single tablet of 500 mcg instead of the required dosage. Additionally, a staff member held two medications for a resident due to a systolic blood pressure reading below 110 mmHg, as per the facility's standing order. However, the staff member failed to document that the medications were held, and the Medication Administration Audit Report inaccurately showed that the medications were administered. This discrepancy was acknowledged by the staff member during a follow-up interview.
Failure in Hand Hygiene During Medication Administration
Penalty
Summary
The facility staff failed to perform proper hand hygiene during medication administration for three residents. During observations in the main dining room, a staff member was seen administering medications to residents without performing hand hygiene between each resident. Specifically, the staff member did not wash hands after administering medications to one resident before preparing medications for another. This occurred despite the staff member touching residents' eating utensils and dishes during the medication pass. When interviewed, the staff member acknowledged that she should have performed hand hygiene between residents but believed it was unnecessary since she did not touch the pills directly.
Failure to Protect Resident from Abuse by Another Resident
Penalty
Summary
The facility failed to protect a vulnerable resident from physical abuse by another resident. Resident #30, who had severe cognitive impairment and exhibited wandering behaviors, was struck on two separate occasions by resident #29. The first incident occurred on 10/17/24, when resident #29, who was having difficulty adjusting to the new environment, struck resident #30 on the right shoulder. The facility's investigation did not identify any possible triggers for the abuse or how resident #30 would be protected from further incidents. Additionally, resident #30's care plan did not address the increased risk of abuse due to her wandering behaviors. A second incident occurred on 10/24/24, when resident #29 hit resident #30 on the head and pulled her hair. Despite the facility's policy to prevent abuse, the care plan for resident #29 did not identify resident #30 as a potential target of abusive interactions. Staff members involved in the investigations of both incidents did not classify them as abuse, citing the residents' cognitive impairments and lack of injuries. However, the facility's failure to protect resident #30 from further abuse was evident, as no effective measures were implemented to prevent recurrence.
Failure to Provide Baseline Care Plan to Resident
Penalty
Summary
The facility failed to provide a copy of the baseline care plan to a resident or the resident's representative, as required. During an interview, the resident stated she did not receive any information or communication regarding her baseline care plan from the facility. Additionally, the resident's representative confirmed that they had not received any communication from the facility about the baseline care plan. A review of the resident's medical record showed no documentation or evidence that the baseline care plan was provided to either the resident or the representative. Despite a request for documentation regarding the provision of the baseline care plan, no information was provided before the end of the survey.
Failure to Address Dental Issues in Care Plan
Penalty
Summary
The facility failed to develop a comprehensive, resident-centered care plan for a resident with dental issues. During an observation, the resident was noted to have broken teeth in her lower jaw. The Social Service History & Initial Assessment documented that the resident had dental problems, specifically broken and decayed teeth. Despite this assessment, the resident's care plan did not include any documentation or planning related to her dental issues or the provision of dental services. A staff member confirmed that such issues should be care planned, indicating a lapse in the facility's care planning process.
Failure to Assess Wheelchair Positioning Needs
Penalty
Summary
The facility failed to identify and assess the wheelchair positioning needs for a resident, leading to discomfort due to a poorly fitting wheelchair. The resident reported that her wheelchair was too narrow and that the oxygen tank positioned on the back of her wheelchair caused her discomfort. Despite informing CNAs about the pain, there was a lack of communication and awareness among staff members regarding the issue. One staff member acknowledged being informed by the resident about the pain and had notified the maintenance department, but another staff member was unaware of any wheelchair maintenance concerns. Additionally, a review of the resident's physical therapy initial examination revealed that she was not evaluated for proper wheelchair positioning.
Failure to Provide Proper Foot Care for Resident
Penalty
Summary
The facility failed to provide appropriate foot care for a resident, resulting in the resident experiencing pain due to a callus on her left foot. The resident reported on December 2nd that she had been experiencing pain from the callus and that the facility had not addressed it. A progress note from September 6th indicated the presence of the callus and mentioned that the foot clinic had been treating it, with the resident expressing a desire for a podiatrist to evaluate the residual callus. A physician's order dated September 9th called for a podiatry consult for the callus, but the appointment was not scheduled. On December 4th, an observation confirmed the presence of the callus, and a staff member stated that the consult had not been scheduled despite the doctor's order.
Failure to Reorder PRN Antipsychotic Medication Every 14 Days
Penalty
Summary
The facility failed to ensure compliance with the 14-day limit on as-needed antipsychotic medications for a resident diagnosed with dementia, anxiety, and depression. The resident was prescribed olanzapine 2.5 mg twice daily as needed for agitation, but the order did not specify a duration or stop date. The resident's medication administration records (MAR) showed multiple doses were administered over several months without the required physician evaluation and reordering every 14 days. Despite a pharmacy progress note indicating the need for reordering, the medication was not appropriately managed, leading to a deficiency in medication administration practices. Interviews with facility staff revealed a lack of adherence to the policy requiring physician evaluation and documentation for the continuation of as-needed psychotropic medications. Staff members were aware of the 14-day limit but failed to ensure the medication was reordered as required. One staff member mistakenly believed the electronic health record system would automatically discontinue the medication, while another did not address the need for reordering in the monthly medication regimen review. The facility's policy on psychotropic medication use was not followed, resulting in the deficiency.
Failure to Discard Expired Dairy Products
Penalty
Summary
The facility failed to properly manage the storage of dairy products, specifically Half and Half, in their walk-in cooler. During observations on two consecutive days, cartons of Half and Half with a use by date of 12/3/24 were found on the top shelf to the right of the entrance. On 12/4/24, 11 cartons were observed, and on 12/5/24, eight cartons remained. During an interview, a staff member acknowledged that dairy products should have been discarded by their use by date, indicating a lapse in adherence to food safety protocols.
Failure to Document and Offer Pneumococcal Vaccines
Penalty
Summary
The facility failed to ensure proper screening and documentation for pneumococcal vaccinations for two residents. Resident #27's vaccination history did not indicate receipt of any pneumococcal vaccines, and staff member J, responsible for immunizations for two months, could not provide information on whether the vaccines were offered, received, or declined since the resident's admission. Similarly, resident #16's vaccination history showed receipt of the Prevnar 13 vaccine but lacked documentation of the Prevnar 20 or Pneumovax 23 being offered, given, or declined. Staff member J was unable to explain the absence of these records.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
