The Valley Health And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Hamilton, Montana.
- Location
- 601 N 10th St, Hamilton, Montana 59840
- CMS Provider Number
- 275135
- Inspections on file
- 20
- Latest survey
- January 28, 2026
- Citations (last 12 mo.)
- 24
Citation history
Health deficiencies cited at The Valley Health And Rehab during CMS and state inspections, most recent first.
The facility failed to serve lunch at its scheduled times, with trays on one unit being delivered 36–47 minutes late on multiple days, despite a written schedule specifying earlier service. A resident on that unit experienced repeated delays, with a family member reporting that meals were often late and that the resident was not allowed to lie down until after lunch, causing frustration when lunch arrived significantly behind schedule and was then refused. Staff interviews confirmed that meals had been running late more frequently, citing short staffing in the kitchen, training of a new cook, and the time required to dish up and pass trays, in contrast to the facility’s policy requiring three daily meals without extensive time lapses.
Surveyors identified a failure to store food according to professional standards when they observed multiple open and prepared food items in the walk-in freezer and refrigerator without labels or dates, including an open bag of French fries, cut tomatoes and onion wrapped in cellophane, and a half-empty pan of red Jello. The dietary supervisor reported that staff are instructed to check received and expiration dates, label and date all open and cut items, and use a posted "Use by Date Guide" as a reminder, and facility policy requires labeling, dating, monitoring refrigerated foods, and keeping foods covered or in tight containers.
Insufficient staffing on the Memory Care Unit resulted in residents not receiving needed ADL care, supervision, and meal assistance. Staff reported being unable to complete required tasks, often skipping baths and showers, and residents were observed unkempt and without proper support. Facility records confirmed multiple days with staffing below assessed needs, directly impacting resident care and safety.
A staff member was found to have engaged in verbally abusive behavior toward vulnerable residents in a secure memory care unit, as reported by another employee and confirmed through interviews. The incident involved yelling at residents during a night shift, with prior negative verbal interactions also substantiated. Residents were assessed for distress following the event, but no acute distress was observed.
Ten residents who required assistance with ADLs did not receive regular showers or adequate hygiene support, as evidenced by observations of unkempt appearance, resident and family complaints, and gaps in shower logs. Residents with conditions such as decreased mobility, Parkinson's disease, and stroke were not consistently assisted with bathing as outlined in their care plans, and facility documentation showed missed or delayed showers despite identified concerns.
The facility did not complete thorough investigations into staff-to-resident verbal abuse and neglect allegations involving two residents, failing to monitor residents, implement documented interventions, or interview other residents and staff. Documentation was incomplete for multiple incidents, and required investigative steps were not followed according to facility policy.
A resident with Alzheimer's disease and severe cognitive impairment exhibited frequent distress, behavioral symptoms, and functional decline. Staff did not implement care-planned interventions such as diversional activities, one-to-one support, or prompt redirection, and failed to provide adequate supervision or monitor interactions with others. Documentation showed minimal activity participation and incomplete mood and behavior assessments, despite the resident's ongoing distress and behavioral issues.
Staff did not consistently use Enhanced Barrier Precautions (EBP) or appropriate PPE when providing high-contact care to two residents with urinary catheters. In both cases, staff either failed to don PPE or only wore gloves despite clear facility policy and signage requiring EBP for residents with indwelling devices during transfers and toileting.
A resident was transferred or discharged without the facility ensuring that their needs and preferences were met, and without adequate preparation for a safe transition.
The facility did not complete a thorough investigation after a staff member was witnessed verbally abusing a resident. Required 72-hour monitoring and emotional support for the affected resident were not documented, and no additional resident interviews were conducted to rule out further abuse concerns, contrary to facility policy.
A resident at risk for nutritional deficits experienced severe weight loss due to inadequate monitoring by the facility. Despite being identified as at risk due to recent weight loss and comorbidities, the resident's weight was not recorded for over a month, resulting in a 25.5-pound loss. The facility's policy required weekly weights for such residents, which was not followed.
The facility failed to maintain safe and palatable food temperatures for residents eating in their rooms. A resident reported receiving cold food, and another mentioned a specific instance of a cold taco. Staff confirmed that food was not kept at the required temperature, with a pancake served at only 100.7°F, below the mandated 135°F. The facility's policy requires hot food to be served at a minimum of 135°F, which was not followed.
A facility failed to ensure a POLST form for a resident was completed with the necessary signature from the resident or their decision-maker. The POLST form, which indicated preferences such as DNR and comfort measures only, lacked a documented signature or printed name. Facility policy requires that advance directives and POLST forms be documented and reviewed, but this was not adhered to in this case.
Late Meal Service and Resident Frustration Due to Delayed Lunch Trays
Penalty
Summary
The deficiency involves the facility’s failure to provide meals at the scheduled times established by its own meal schedule, resulting in resident frustration. The facility’s posted meal schedule indicated that lunch trays for Birch Hall residents were to be delivered at 12:20 p.m. However, observations on two separate days showed that lunch trays were passed significantly later than scheduled: at 12:56 p.m. on one day (36 minutes late) and at 1:07 p.m. on another day (47 minutes late). On one of these days, the last lunch tray to Birch Hall was still being delivered at 1:14 p.m. Staff interviews confirmed that meals were sometimes late, that residents often sat waiting in the dining room for extended periods, and that meals had been served late more frequently recently. One resident, identified as resident #31, was directly affected by these delays. On one day, the resident’s lunch tray was delivered to his room at 12:56 p.m., and a family member (NF1) reported that lunch meals were often served late and that “you get used to it over time.” On another day, NF1 approached staff to ask where the lunch meal was, stating that the resident wanted to lie down but had been told he could not do so until after lunch, and that he was not happy lunch was so late. When the tray was finally delivered at 1:07 p.m., the resident expressed dissatisfaction with the meal, and NF1 returned the tray and ordered an alternative. Staff interviews attributed the late meals to factors such as training a new cook, being short two kitchen staff members, and the time it took staff to dish up and pass the meals, despite a facility policy stating that residents would receive at least three meals daily without extensive time lapses between meals.
Failure to Label and Date Open and Prepared Food Items in Dietary Storage
Penalty
Summary
Surveyors found that the facility failed to store food in a sanitary manner in the dietary department. During an observation of the walk-in coolers, an open bag of French fries was found in the freezer with no label or date. In the refrigerator, two halves of a tomato wrapped in cellophane, half of an onion wrapped in cellophane, and a large pan of half-empty red Jello were also observed without any labels or dates. These items were not labeled or dated as required by facility policy. In an interview, the dietary staff member responsible for directing dietary staff stated that she instructs staff to check the received date and expiration date when they open an item and to place a label and date on any open items and anything cut and wrapped in cellophane. She reported that she continues to remind staff to label open items and indicated that a "Use by Date Guide" was posted on the outside of the refrigerator door as a reminder of the rules for dating open items. Review of the facility’s Food Safety Requirements policy confirmed that food is to be stored in accordance with professional standards, including labeling, dating, and monitoring refrigerated food such as leftovers so it is used by its use-by date or discarded, and keeping foods covered or in tight containers.
Insufficient Staffing Leads to Inadequate Resident Care and Supervision
Penalty
Summary
The facility failed to provide sufficient nursing staff on the Memory Care Unit to meet the needs of residents, resulting in inadequate monitoring, assistance with activities of daily living (ADLs), meal assistance, and abuse prevention. Multiple observations and staff interviews revealed that residents were left unsupervised, including those requiring one-to-one supervision due to disruptive behaviors. Staff reported being unable to complete all required tasks during their shifts, often skipping baths and showers due to time constraints and insufficient staffing. Residents were observed wearing the same clothing over consecutive days, appearing unkempt, and not receiving scheduled or needed bathing services. Further observations documented residents without appropriate assistance during meals, such as a resident eating with her fingers and pouring water onto her plate without staff intervention. Staff consistently reported that the lack of adequate staffing made it difficult to provide necessary care, particularly for bathing and supervision. The facility's own records confirmed that on several days, staffing levels were below what was identified as necessary in the facility assessment, directly impacting the quality of care provided to residents. Documentation and interviews indicated that the facility had identified staffing as an ongoing issue, particularly affecting the provision of ADL care and resident supervision. The lack of staff also affected the ability to provide activities and ensure resident safety, with staff expressing concerns about their inability to protect residents and complete essential care tasks. The deficiency was supported by observations, interviews, and record reviews, all indicating a pattern of insufficient staffing leading to unmet resident needs.
Verbal Abuse of Vulnerable Residents in Memory Care Unit
Penalty
Summary
A staff member on the memory care unit was reported to have engaged in verbally abusive behavior toward residents. The incident was initially brought to attention when a CNA reported, via text message, that an employee had been yelling at residents during the night shift. The report did not specify which residents were involved or the exact language used, but all residents in the memory care unit were identified as vulnerable. Subsequent interviews confirmed that the staff member in question had previously demonstrated negative verbal interactions with residents. The facility's investigation substantiated the allegation of verbal abuse, confirming that the staff member had engaged in inappropriate verbal conduct toward residents on more than one occasion. At the time of the incident, residents were assessed for signs of distress or behavioral changes, but no acute distress was noted. The deficiency centers on the occurrence of verbal abuse directed at vulnerable residents in the secure memory care unit by a staff member.
Failure to Provide Regular Showers and ADL Assistance
Penalty
Summary
The facility failed to provide regular showers and adequate assistance with activities of daily living (ADLs) for 10 out of 18 sampled residents who were unable to perform these tasks independently. Observations and interviews revealed that multiple residents appeared unkempt, with oily or matted hair, and expressed feelings of being dirty or neglected due to missed or infrequent bathing. Shower logs confirmed significant gaps between baths, with some residents going up to 16 days or more without a shower, and in one case, a resident did not receive any bath in a 30-day period. Residents' care plans consistently indicated the need for staff assistance with bathing due to various medical conditions such as decreased mobility, Parkinson's disease, stroke, and memory deficits. Several residents and their families reported concerns about hygiene and the lack of regular bathing. For example, one resident stated that staff refused to help with baths, resulting in missed showers and feelings of being dirty. Another resident's family contacted the facility to express concern about the resident's matted hair and infrequent bathing. Residents' care plans outlined specific interventions, such as offering bed baths if showers were declined and notifying nursing staff if both were refused, but documentation and interviews indicated these interventions were not consistently implemented. A review of the facility's Quality Assurance and Performance Improvement (QAPI) Performance Improvement Project (PIP) action plan identified issues with staffing, adherence to bathing schedules, and documentation as root causes for the deficiency. Despite recognizing the problem, the facility did not follow through with corrective actions, as evidenced by ongoing missed or delayed showers for multiple residents. Facility policy required that care and services for ADLs, including bathing, be provided based on comprehensive assessment and resident needs, but this standard was not met for the affected residents.
Failure to Complete Thorough Abuse and Neglect Investigations
Penalty
Summary
The facility failed to conduct thorough investigations into allegations of staff-to-resident verbal abuse and neglect involving two residents. Specifically, the facility did not complete resident monitoring, did not implement interventions that were identified and documented in the incident reports, and did not interview other residents to determine if additional individuals were affected. Documentation for several incidents was incomplete, lacking summaries, evidence of staff education, and records of monitoring activities such as bathing logs or audits. Interviews with staff revealed that investigation folders had not been fully reviewed and that the investigations were still in progress, despite being part of a plan of correction from a previous complaint survey. The facility's own policy requires comprehensive investigation procedures, including reporting, analysis, staff training, and monitoring, but these steps were not documented or carried out as required for the incidents in question.
Failure to Implement Dementia Care Interventions and Supervision
Penalty
Summary
The facility failed to provide appropriate services, treatment, and interventions for a resident diagnosed with Alzheimer's disease and dementia, who exhibited significant cognitive and functional decline. The resident displayed frequent physical and verbal behaviors, including crying, yelling, wandering, and making statements indicating pain, fear, and distress. Despite these behaviors, staff did not implement the care-planned interventions such as providing diversional activities, one-to-one support, or prompt redirection when the resident was upset. Observations showed the resident calling out for help, expressing fear, and making statements about not wanting to live, without staff intervention or support. Interviews with staff revealed that the resident required constant supervision and had a history of altercations with other residents. Staff acknowledged that there was insufficient supervision and that activities for dementia care were lacking or only recently initiated. Documentation showed that the resident participated in very few activities over a two-month period, despite care plan interventions specifying the need for engagement in activities of interest and avoidance of overstimulation. Staff also failed to monitor and intervene during verbal altercations between residents, as required by the care plan. Review of the resident's health records and Minimum Data Set (MDS) assessments indicated severe cognitive impairment, increased behavioral symptoms, and a decline in functional abilities. The resident was unable to complete mood interviews, and staff assessments were either incomplete or blank. The care plan identified the resident as being at risk for verbal abuse from others due to her behaviors, yet the documented interventions were not consistently implemented, resulting in unaddressed distress and behavioral symptoms.
Failure to Implement Enhanced Barrier Precautions for Residents with Catheters
Penalty
Summary
Staff failed to consistently implement Enhanced Barrier Precautions (EBP) for residents with indwelling urinary catheters, as required by facility policy. During observations, one staff member was seen leaving a resident's room after assisting with a transfer using a mechanical lift, without donning any personal protective equipment (PPE). The resident had a catheter in place, and there was no PPE caddy available outside the room. The staff member admitted to not using PPE and stated she intended to retrieve supplies afterward. The resident confirmed that PPE was not always used during catheter care and noted that PPE supplies had previously been available but were removed, leading to more relaxed practices among staff. In another instance, a staff member entered a different resident's room, which had signage and a PPE caddy indicating the need for EBP, but did not don PPE before assisting the resident, who also had a catheter, with a transfer to the toilet. The staff member only wore gloves and stated she had just been informed that day about the requirement for PPE use with catheters. Interviews with other staff confirmed that EBP should be used for residents with wounds, catheters, or multidrug-resistant organisms during high-contact care tasks, such as transferring and toileting. Review of the facility's policy confirmed these requirements, but observations and interviews demonstrated inconsistent adherence.
Failure to Ensure Safe and Resident-Centered Transfer/Discharge
Penalty
Summary
The facility failed to ensure that the transfer or discharge process met the resident's needs and preferences, and did not adequately prepare the resident for a safe transfer or discharge. This deficiency was identified based on observations and documentation showing that the necessary steps to assess and address the resident's individual requirements and preferences during the transfer or discharge process were not completed. As a result, the resident was not fully prepared for a safe transition to the next care setting.
Failure to Complete Thorough Abuse Investigation and Resident Monitoring
Penalty
Summary
The facility failed to conduct a thorough investigation following an incident of staff-to-resident verbal abuse witnessed by several management staff. Although the staff member involved was immediately removed from the facility, the investigation documentation indicated that the resident was to be placed on every-shift monitoring for 72 hours and provided with one-on-one emotional support. However, review of the resident's nursing progress notes, Medication Administration Record (MAR), and Treatment Administration Record (TAR) for the 72 hours after the incident revealed only a single progress note two days post-incident, which described the resident as somnolent and refusing some care, with no interventions noted for these behavioral changes. There was no documentation of the required monitoring or emotional support, and the MAR and TAR did not reflect the monitoring order. Additionally, the facility did not conduct interviews or assessments with other residents to determine if there were further concerns of abuse by the same staff member, as required by facility policy. Staff interviews confirmed that no additional resident interviews were performed, and all investigation materials were limited to the file provided. The facility's policy mandates identifying and interviewing all involved persons and providing emotional support to affected residents, but these steps were not completed in this case.
Failure to Monitor Resident's Weight Leads to Severe Weight Loss
Penalty
Summary
The facility failed to adequately monitor a resident at risk for nutritional deficits, leading to severe weight loss. A staff member indicated that CNAs were responsible for checking the EHR to determine which residents needed to be weighed, with varying frequencies such as monthly, weekly, or daily. However, there was a lapse in monitoring as the resident did not have weights recorded from late September to early November, during which time the resident experienced a significant weight loss of 25.5 pounds. The resident, who was already at risk due to recent weight loss, inadequate food intake, and comorbidities including wounds, was not weighed according to the facility's policy for residents with weight loss, which required weekly monitoring. The resident expressed concerns about his weight loss and mentioned that he had only recently started receiving daily weights to assess the need for a medication that increased urination. Despite the resident's thin appearance and his report of weight loss, the facility did not ensure consistent weight monitoring. A staff member acknowledged the oversight in obtaining regular weights and noted that the resident's nutrition assessment was updated in November, but by then, the resident had already experienced severe weight loss. The facility's policy required weekly weights for residents with weight loss, which was not adhered to in this case.
Failure to Maintain Safe Food Temperatures
Penalty
Summary
The facility failed to maintain safe and palatable temperatures for food served to residents in their rooms, affecting three of the nineteen sampled residents. Resident #18 reported that their food was cold upon arrival in their room. Resident #3, who ate all meals in their room, also complained about the food being cold and unappetizing, mentioning a specific instance where a taco was served cold. Resident #13, who ate meals both in their room and the dining room, stated that breakfast served in their room was not warm enough. These residents expressed dissatisfaction with the temperature and quality of the food served. Observations and interviews with staff revealed that food was cooked and held at 135 degrees Fahrenheit in a steam table before being served. However, meals for residents eating in their rooms were left in the steam table until after dining room meals were served, leading to a delay. Staff member F confirmed that the temperature of a pancake served to resident #18 was only 100.7 degrees Fahrenheit, below the required 135 degrees Fahrenheit. The facility's policy mandates that hot food items must be cooked, held, and served at a minimum of 135 degrees Fahrenheit, which was not adhered to in these instances.
Incomplete POLST Form Lacks Required Signature
Penalty
Summary
The facility failed to ensure that a POLST form for one of the sampled residents was completed with the necessary signature from the resident or their decision-maker. During an interview, a staff member explained that residents or their representatives are asked about their advance directives upon admission, and these directives are reviewed during the initial care conference. However, a review of the electronic medical record for the resident in question revealed that the POLST form lacked a documented signature or printed name of the patient or decision-maker, despite indicating preferences such as DNR, comfort measures only, and no artificial nutrition by tube. The facility's policy requires that advance directives and POLST forms be documented in a prominent part of the resident's medical record and reviewed periodically. The policy also mandates staff training on these procedures. However, the resident's care plan and the facility's policy both emphasize the importance of having a signed POLST form, which was not adhered to in this case. The absence of a signature on the POLST form indicates a failure to comply with the facility's procedures and the legal requirements for validating such documents.
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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