Village Health & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Missoula, Montana.
- Location
- 2651 South Ave W, Missoula, Montana 59804
- CMS Provider Number
- 275043
- Inspections on file
- 27
- Latest survey
- November 19, 2025
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at Village Health & Rehabilitation during CMS and state inspections, most recent first.
The facility did not submit investigation findings for a resident-to-resident incident to the State Survey Agency within the required five-day period, resulting in a late report for two residents involved in the event.
A deficiency was cited when a facility area was not kept free from accident hazards and supervision was inadequate to prevent accidents. The environment and oversight did not meet required standards to minimize accident risks.
A resident with a history of hip replacement complications fell during a transfer when left unsupported by a nurse. Staff did not promptly notify the physician as required by facility protocol, resulting in delayed treatment for a fracture and unmanaged pain. Documentation did not reflect timely physician notification, contrary to facility policy.
Two residents were involved in a physical altercation where one reported being touched inappropriately by another. Although the incident was documented and communicated internally, the allegation was not reported to the State Survey Agency within the required 24-hour period, as required by facility policy. Staff interviews indicated a lack of awareness of the reporting requirement, and video evidence of the incident was no longer available for review.
Staff did not consistently use required PPE when caring for residents on special droplet/contact and contact precautions, with missing N-95 masks and lack of eye protection observed. In addition, staff and visitors were not properly educated or monitored regarding cleaning and precautionary practices for residents with C. diff, resulting in improper room cleaning and delayed notification of necessary precautions. Facility policies outlining PPE and cleaning requirements were not consistently followed or communicated.
The facility failed to maintain a clean environment for residents, with observations revealing sticky substances and debris in rooms. Residents reported infrequent cleaning, and staff confirmed understaffing in housekeeping, leading to inadequate cleanliness. Despite claims of daily cleaning, observations showed neglected areas, particularly under beds.
The facility failed to update care plans in a timely manner for residents with pressure ulcers and behavioral issues. A resident with a stage III pressure ulcer had their care plan updated over two months later, while another resident's care plan for a pressure ulcer was delayed by nearly a month. Additionally, a resident involved in altercations had their care plan updated weeks after the incidents. These delays indicate a failure to provide timely interventions for both pressure ulcer management and behavioral issues.
A facility failed to accurately assess a resident involved in altercations, potentially affecting care and safety. The resident's evaluation inaccurately showed no history of abuse or behaviors making them susceptible to abuse, despite nurse's notes documenting confusion, agitation, and disruptive behaviors. A staff member admitted to not thoroughly considering the resident's behaviors during the evaluation.
A facility failed to limit an as-needed anti-anxiety medication order to 14 days or provide a rationale for its continued extension for a resident using Lorazepam. The medication was re-ordered multiple times without justification, and the facility did not provide documentation of education or consent for its use. The facility administered the medication without addressing the source of the resident's agitation, contrary to its policy.
A resident with a history of falls and impaired mobility fell and sustained a hip fracture after mistakenly using the bed control instead of the call light, which was out of reach. The bed was elevated, and the resident attempted to get up, resulting in the fall. Staff interviews revealed inconsistencies in call light placement, and documentation of rounds was not provided.
The facility failed to ensure proper food safety and hygiene practices, as staff with facial hair did not wear beard coverings, and food items in the walk-in freezer were not labeled or dated. Additionally, leftover chicken was not properly cooled, and the responsible staff member was unaware of the correct procedures, with no food cooling logs available.
A facility failed to implement a baseline care plan within 48 hours for a newly admitted, nonverbal resident with a subdural hematoma and stroke, who was totally dependent on staff for ADLs. The care plan was delayed, with initiation occurring several days post-admission, contrary to the facility's policy. A staff member admitted to occasionally forgetting to complete these plans on time.
A resident with a PTSD diagnosis did not have a care plan in place, leading to staff being unaware of her condition and triggers. This resulted in an incident where her PTSD was triggered by a CNA entering her room abruptly. A staff member confirmed the lack of a care plan and was unaware of the resident's PTSD diagnosis.
A facility failed to update a resident's care plan regarding catheter management after the resident and their POA decided to discontinue urology clinic appointments and focus on comfort care. The care plan, last updated months prior, still listed the clinic as responsible for catheter management, without reflecting the new focus on comfort care and the management of scheduled and PRN catheter changes.
A facility failed to manage catheter changes as ordered for a resident with a suprapubic catheter, leading to frequent changes due to clogging. The staff did not adjust scheduled change dates after PRN changes and missed documentation for catheter flushes. The resident reported bladder pain, but no recent infections were documented.
A resident missed a dialysis appointment due to the facility's failure to provide transportation. The resident was waiting for a van but could not open the door due to a coded keypad, and the transportation company left after calling the facility without an answer. The resident was later hospitalized and in the ICU for three days. The facility had an agreement stating it was responsible for arranging transportation.
A resident with PTSD did not receive necessary behavioral health services at the facility. The resident reported a lack of communication about her PTSD and minimal interaction with the social worker. She experienced a triggering incident and expressed a need for support, especially regarding her dialysis treatment decisions. Staff were unaware of her PTSD diagnosis and did not facilitate mental health referrals or contact with her personal counselor. Her care plan lacked guidance for managing her PTSD.
The facility failed to follow infection control practices during pericare and wound care for a resident, as staff did not sanitize surfaces or change gloves and perform hand hygiene. Additionally, enhanced barrier precautions were not implemented for a resident with a PICC line, as required by facility policy.
Late Submission of Investigation Findings for Resident Incident
Penalty
Summary
The facility failed to submit investigation findings for a resident-to-resident incident to the State Survey Agency within the required timeframe for two of nine sampled residents. The incident was initially reported to the State Survey Agency, but the facility's investigation findings were submitted one day late, after the five-day deadline had passed. During an interview, a staff member confirmed that such incidents are to be reported within 24 hours and investigation findings submitted within five days, excluding weekends and holidays. Review of the facility's policy confirmed these reporting requirements.
Failure to Maintain Accident-Free Environment and Provide Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment was not maintained in a manner that would minimize the risk of accidents, and supervision protocols were insufficient to prevent such incidents from occurring. No additional details regarding the specific individuals involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Promptly Notify Physician After Resident Fall Resulting in Injury
Penalty
Summary
A deficiency occurred when facility staff failed to promptly notify a physician after a resident experienced a fall that resulted in injury and pain. The resident, who had a history of complications following a right hip replacement, reported falling during a transfer when left unsupported by a nurse who went to seek assistance. Staff interviews confirmed that the established fall protocol required immediate notification of the physician and family, but the responsible staff member did not notify the on-call physician after the incident. Documentation in the resident's electronic health record did not show timely physician notification regarding the fall and the resident's increased pain. The delay in physician notification led to a delay in treatment, and the resident was later found to have sustained a fracture. Facility policy and the fall prevention program both required prompt notification of the physician and family following an accident resulting in injury. The lack of timely communication with the physician impacted the opportunity for the physician to provide directives on the resident's care, pain management, and injury assessment.
Failure to Timely Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an allegation of resident-to-resident abuse to the State Survey Agency within the required 24-hour timeframe. Specifically, two residents were involved in a physical altercation in which one resident reported that another had touched his groin. The incident was initially reported by the resident to nursing staff on the evening it occurred, and this was documented in the nursing progress notes. The staff communicated the incident internally to social services and the DON, but the allegation was not reported to the State Survey Agency until several days later. Staff interviews revealed a lack of awareness regarding the reporting requirement and confusion about the need to report when the resident later denied the incident occurred. Facility policy requires immediate reporting of suspected abuse, including sexual abuse, to the State Survey Agency and other authorities within specified timeframes. Despite this, the initial allegation was not reported as required, and the facility's video surveillance of the incident was no longer available for review at the time of the survey. The deficiency was identified through interviews, record review, and examination of facility policy, which clearly outlines the obligation to report such incidents promptly.
Failure to Adhere to PPE and C. diff Cleaning Protocols
Penalty
Summary
Facility staff failed to consistently wear appropriate personal protective equipment (PPE) while caring for residents under special droplet/contact and contact precautions. Observations revealed that PPE supply containers in multiple hallways lacked N-95 masks, and staff were seen entering and exiting rooms with special droplet/contact precaution signage while wearing only procedural masks and without required eye protection. In one instance, a staff member was unaware of the need to wear a mask throughout the facility, and another staff member entered a contact precaution room without donning any PPE, only putting on gloves after entering to handle a resident's catheter bag. Signs indicating required precautions were not always followed, and doors that were supposed to remain closed were observed open. The facility also failed to adequately educate and monitor staff regarding cleaning practices for residents with Clostridioides difficile (C. diff) infections. Family members visiting a resident were not informed of the need to wear gowns and gloves or to avoid bringing an infant into a room where a roommate had tested positive for C. diff, only being notified after several visits. Staff interviews revealed a lack of knowledge about the appropriate cleaning agents and procedures for C. diff, with some staff unable to identify the correct cleaning solution or required contact time for disinfection. There was also uncertainty about whether a written process for cleaning rooms of residents with C. diff existed, and housekeeping staff had not been specifically trained on these procedures. Review of facility policies confirmed that staff were expected to adhere to specific PPE requirements for COVID-19 and C. diff, including the use of N95 respirators, gowns, gloves, and eye protection for COVID-19, and daily cleaning with a sporicidal agent for C. diff. However, these protocols were not consistently implemented or communicated to staff, leading to lapses in infection prevention and control practices for multiple residents.
Facility Fails to Maintain Clean Environment for Residents
Penalty
Summary
The facility failed to maintain a clean and homelike environment for its residents, as evidenced by observations and interviews with residents and staff. Resident #72 reported that her room had not been mopped for several days, with a sticky substance remaining on the floor. Observations confirmed the presence of a red sticky substance and debris under the bed. Resident #16 and another individual noted that the floors were not cleaned regularly, with dark spots remaining for several days. Resident #95 also mentioned that the rooms were not cleaned frequently, with heavy black stains and debris observed around the door frames. Staff interviews revealed that the facility was understaffed in housekeeping, leading to inadequate cleaning of resident rooms. Staff member F claimed that beds were cleaned under daily, but observations contradicted this, showing dirt and debris under the beds. Staff member G acknowledged that while the halls were relatively clean, the resident rooms were not, and areas under the beds were particularly neglected. Staff member S confirmed the facility's cleanliness issues, attributing them to a shortage of housekeeping staff and the inability of nursing staff to compensate for the lack of cleaning.
Delayed Care Plan Updates for Pressure Ulcers and Behavioral Issues
Penalty
Summary
The facility failed to update and revise care plans in a timely manner for residents with pressure ulcers and behavioral issues. Resident #1 had a new wound identified as a stage III pressure ulcer on the left heel on 9/6/24, but the care plan was not updated to reflect this until 11/18/24. Similarly, resident #16 had a stage III pressure ulcer on the right heel identified on 10/22/24, but the care plan was not updated with interventions until 11/18/24. Resident #55 developed a new in-house acquired pressure ulcer on 10/28/24, but the care plan was not updated until 11/18/24. These delays in updating care plans indicate a failure to provide timely interventions for pressure ulcer management. Additionally, the facility failed to revise the care plan for resident #33 in response to repeated resident-to-resident altercations. On 8/29/24, resident #33 was involved in an altercation where he smacked another resident, and on 8/30/24, he was hit by another resident. The care plan was not updated until 9/10/24, and further updates were not made until 10/11/24. The care plan updates included interventions such as sitting on the opposite side of the dining room from louder residents and using music as a form of expression. The delay in updating the care plan for behavioral interventions highlights a lack of timely response to resident behavioral issues.
Inaccurate Resident Assessment in LTC Facility
Penalty
Summary
The facility failed to complete accurate assessments for a resident involved in two altercations, which could potentially affect resident care and safety. The resident's vulnerable resident evaluation dated 9/30/24 inaccurately indicated that the resident did not have a history of abuse toward others or behaviors that would make them susceptible to abuse by others. Additionally, the resident's MDS with an ARD of 10/3/24 showed no physical, verbal, or other behavior symptoms directed toward others. However, nurse's notes from 9/28/24 and 10/2/24 documented the resident's increasing confusion, agitation, and disruptive behaviors, which required administration of prn antianxiety medication. During an interview, a staff member admitted to completing the evaluation without thoroughly considering the resident's behaviors, acknowledging that the evaluation should have been more accurate.
Failure to Limit and Justify PRN Anti-Anxiety Medication Use
Penalty
Summary
The facility failed to limit an as-needed anti-anxiety medication order to 14 days or provide a rationale for its continued extension for a resident using Lorazepam. The medication was initially ordered for 4 days but was not administered during that period. Despite this, the medical provider re-ordered the medication for another 14 days without justification, and again for 6 months, even though the resident had not received any doses until later. The facility did not provide documentation of education or consent for the use of Lorazepam, and the resident's representative was not informed about the risks or benefits of the medication. The facility's policy requires that psychotropic medications be initiated only after addressing medical, physical, functional, psychosocial, and environmental causes. However, the facility administered Lorazepam to the resident without addressing the source of agitation, which was related to a staff member. The physician was aware of the medication's administration but did not document a rationale or diagnosis for its continuation. The facility's failure to adhere to its policy and lack of documentation for the medication's use contributed to the deficiency.
Resident Fall Due to Inaccessible Call Light and Elevated Bed
Penalty
Summary
The facility failed to provide a safe environment for a resident, resulting in a fall and significant injury. The resident, who had a history of falls and required assistive devices, was found on the floor with a left elbow skin tear and complained of left hip pain. The resident's bed was in the highest position, and the call light was not within reach, leading the resident to mistakenly use the bed control instead of the call light. This caused the bed to elevate, and the resident attempted to get up, resulting in a fall and a left hip fracture. Interviews with staff revealed discrepancies in the availability and placement of the call light. One staff member stated that the call light was on the bedside table, too far for the resident to reach, while another mentioned that the call light was on the floor due to a short cord. The resident had called 911 himself after the fall. Documentation of rounds and the facility's rounding policy were requested but not provided before the survey exit, indicating a lack of proper documentation and adherence to safety protocols.
Food Safety and Hygiene Deficiencies in Kitchen
Penalty
Summary
The facility failed to ensure proper food safety and hygiene practices in the kitchen, as observed during a series of inspections. Staff members with facial hair were repeatedly seen not wearing beard coverings while working in the kitchen, despite the facility's policy requiring hair restraints to prevent hair from contacting food. This was observed on multiple occasions with different staff members, indicating a lack of adherence to the established guidelines for food preparation and handling. Additionally, the facility did not label or date food items stored in the walk-in freezer, including Danish pastries, birthday cakes, and a yellowish substance in small drink cups. This lack of labeling was confirmed by staff members who acknowledged the oversight. Furthermore, the facility failed to properly cool leftover chicken, as it was left sitting out on the counter for an extended period before being placed in the cooler. The staff member responsible was unaware of the proper cooling procedures and could not locate the required food cooling logs, which are essential for ensuring food safety. These deficiencies in food handling and storage practices had the potential to affect all residents consuming food from the facility's kitchen.
Failure to Implement Timely Baseline Care Plan for New Resident
Penalty
Summary
The facility failed to implement a baseline care plan within the required 48-hour timeframe for a newly admitted, nonverbal resident diagnosed with a subdural hematoma and stroke. This resident was totally dependent on staff for activities of daily living, including eating. The electronic health record indicated that the resident was admitted at 1:00 PM, but the baseline care plan was not initiated until several days later, with one focus area starting on the third day and others not until the fifth day or later. During an interview, a staff member acknowledged that the baseline care plan should have been completed on the first day of the resident's stay, as per the facility's policy. The staff member admitted to occasionally forgetting to complete these plans in a timely manner, and the delay in completing the baseline care plan for this resident did not meet her expectations. The facility's policy, reviewed in October 2023, clearly states that a baseline care plan must be developed within 48 hours of admission to ensure effective and person-centered care.
Failure to Develop PTSD Care Plan for Resident
Penalty
Summary
The facility failed to initiate a care plan for a resident diagnosed with unspecified PTSD upon admission. The absence of a care plan meant that staff were not informed of the resident's PTSD triggers or the best ways to assist her in coping with triggering events. A trauma screening tool was completed, but the resident denied experiencing trauma, and no further documentation was provided to identify trauma despite the diagnosis. During an interview, the resident reported that her PTSD was triggered when a CNA entered her room abruptly, suggesting that staff awareness of her condition could have prevented this incident. Additionally, a staff member confirmed being unaware of the resident's PTSD diagnosis and acknowledged that no care plan had been developed to address it.
Failure to Update Care Plan for Catheter Management
Penalty
Summary
The facility failed to update the care plan for a resident regarding catheter care. The resident, who had been under the care of a local urology clinic for catheter management, decided with their Power of Attorney (POA) to discontinue appointments with the clinic and focus on comfort care. Despite this change, the care plan was not updated to reflect the new approach to care, including the discontinuation of urology appointments and the management of scheduled and PRN catheter changes. The care plan still listed the urology clinic as responsible for the catheter management, which was last updated several months prior to the decision to focus on comfort care.
Failure to Manage Catheter Changes as Ordered
Penalty
Summary
The facility failed to manage catheter changes as ordered by the physician for a resident with a suprapubic catheter, leading to multiple catheter changes within short intervals. The resident's catheter was supposed to be changed every three weeks, but due to clogging issues, it was changed more frequently without adjusting the scheduled change dates. This resulted in the catheter being changed four times in three weeks in May, three times in June, and three times in July. The staff did not document the necessary adjustments to the scheduled catheter change dates after performing as-needed (PRN) changes, which were required due to clogs or malfunctions. Interviews with staff revealed a lack of awareness regarding the need to adjust the scheduled catheter change dates following PRN changes. Additionally, there was missing documentation for the administration of catheter flushes intended to prevent clogging, which were ordered to be performed twice daily. The resident reported experiencing burning pain in the bladder, which was known to the facility staff, yet there was no indication of recent infections or pain complaints documented. The failure to adhere to the physician's orders and properly document catheter care increased the risk of infection and complications for the resident.
Failure to Provide Transportation for Dialysis Appointment
Penalty
Summary
The facility failed to ensure transportation was provided for a dialysis appointment for a resident who required such services. On the morning of February 10, 2024, the resident was waiting in the reception area for transportation to a dialysis appointment. Although the transportation van arrived, the resident was unable to open the front door due to a coded keypad, and the transportation company left after calling the facility without receiving an answer. As a result, the resident missed the dialysis appointment. Following the missed appointment, the resident had to be hospitalized and was in the ICU for three days. Interviews with staff revealed that the transportation company would not wait if there was no answer from the facility, and the facility would provide transportation if they found out a resident missed the bus. The facility had a Memorandum of Agreement with the dialysis facility, stating that the LTC facility was solely responsible for arranging transportation for its patients.
Failure to Provide Behavioral Health Services for Resident with PTSD
Penalty
Summary
The facility failed to provide necessary behavioral health services to a resident diagnosed with PTSD. The resident reported that none of the facility's staff had discussed her PTSD with her, and she experienced a triggering incident when a certified nurse assistant abruptly entered her space. Despite this incident, the resident stated that she had minimal interaction with the social worker and had not developed any relationships with the staff, who were perceived as too busy. The resident expressed a need for someone to talk to, especially as she was struggling with decisions regarding her dialysis treatment. She also mentioned that she had not been offered an appointment with a mental health provider or assistance in contacting her personal mental health provider. Staff member G, during an interview, admitted to not being aware of the resident's PTSD diagnosis and did not make any local referrals for mental health care. Additionally, staff member G was unaware of the resident's existing mental health counselor and did not assist in facilitating contact or arranging a private space for communication. A review of the resident's electronic medical record revealed no referrals for mental health services, and her care plan lacked identification of PTSD triggers or guidance for staff on managing her condition.
Infection Control and Barrier Precaution Deficiencies
Penalty
Summary
The facility failed to ensure proper infection control practices during pericare and wound care for a resident. During an observation, a staff member did not sanitize the bedside table before placing wound care supplies on it. Another staff member, who was assisting with the dressing change, did not change gloves or perform hand hygiene after removing a soiled brief and performing pericare. This staff member acknowledged the failure to change gloves or practice hand hygiene during the procedure. The facility's policy required hand hygiene before and after resident contact and after handling soiled items, which was not followed in this instance. Additionally, the facility did not implement enhanced barrier precautions for a resident with a PICC line. Observations revealed that there was no signage or personal protective equipment indicating the need for enhanced barrier precautions outside the resident's room. A staff member confirmed that enhanced barrier precautions were required for residents with indwelling medical devices, such as a PICC line, and that a sign should have been placed on the door. The facility's policy stated that enhanced barrier precautions should be initiated for residents with indwelling medical devices, which was not adhered to in this case.
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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