Whitefish Care And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Whitefish, Montana.
- Location
- 1305 E 7th St, Whitefish, Montana 59937
- CMS Provider Number
- 275132
- Inspections on file
- 31
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 33
Citation history
Health deficiencies cited at Whitefish Care And Rehabilitation during CMS and state inspections, most recent first.
Nursing staff failed to consistently obtain weekly weights and did not recognize severe weight loss in a resident, despite physician orders. Multiple residents were not properly monitored or tracked for hydration status, resulting in hospitalizations for dehydration-related conditions. Staff interviews revealed confusion about responsibilities and inconsistent documentation of food and fluid intake, with hydration tracking removed from the charting system for most residents.
Nursing staff did not consistently assess, monitor, or document a resident’s clinical decline, including changes in mental status, vital signs, intake, and weight. This lack of documentation and communication led to the resident developing severe complications such as dehydration, acute renal failure, and sepsis, ultimately resulting in hospitalization.
Multiple residents and family members reported that staff frequently failed to address all resident needs, displayed poor attitudes, and sometimes mocked or used inappropriate language toward residents. Observations and grievance records revealed instances of staff refusing reasonable requests, neglecting basic care, and making insensitive remarks, leading to residents feeling disrespected and uncared for. These actions and inactions resulted in a lack of confidence in the grievance process and fear of retaliation among residents.
Several residents did not consistently receive or have documented their scheduled showers, with gaps in care and incomplete records. Family members and residents reported unmet hygienic needs, missed showers, and concerns about safety and documentation practices. Staff interviews and record reviews confirmed inconsistencies between paper and electronic documentation, and facility protocols for shower provision and refusal documentation were not reliably followed.
Multiple residents experienced unmet needs and safety concerns due to inaccessible or non-functional call lights, including one resident unable to locate his call light, a wheelchair-bound resident left unattended in a shower room without a reachable call system, and several residents reporting long wait times or repeated requests for assistance. Staff interviews and facility records confirmed frequent call light malfunctions and numerous related grievances.
Three residents were found to have unclean rooms, with visible dirt and garbage such as paper and medical items under beds and in living areas. Residents and staff reported inconsistent cleaning practices, and facility cleaning records were incomplete or missing for the relevant days.
A resident who was unable to independently perform oral care did not receive assistance with teeth brushing as required, despite reminders and staff awareness. Interviews revealed inconsistent ADL support among CNAs, and the facility's policy to provide necessary hygiene services for dependent residents was not followed.
A staff member who was not wound certified did not follow physician orders for a resident's wound care, applying an unprescribed calcium alginate dressing and failing to perform proper hand hygiene during the dressing change.
Surveyors found that the facility failed to maintain accident-free areas and provide adequate supervision, including leaving a wheelchair-bound resident unattended in a shower room without a call light, not ensuring fall prevention interventions such as fall mats and accessible call lights for a high-fall-risk resident, and not providing consistent hydration or oxygen for another resident who experienced multiple falls with head injuries.
A resident with a dental abscess did not receive necessary dental care due to lack of coordination among staff regarding insurance coverage and payment resources. The resident's dental procedure was canceled after staff believed payment could not be arranged, despite the facility having resources and the resident's Medicaid status pending. This led to ongoing dental infection, pain, difficulty eating, and significant weight loss.
The facility did not provide timely COVID-19 vaccination to two residents who later became ill, despite requests and expressed willingness to receive the vaccine. Staff cited physician recommendations and vaccine unavailability from the pharmacy as reasons for the delay, and documentation for vaccination consent or declination was missing for one resident. The outbreak began before vaccines were available, and most residents were only offered the vaccine after the outbreak had started.
A suspected sexual abuse event occurred between two residents, where one was found in another's room with inappropriate contact. Although staff notified police shortly after the incident, the required report to the State Survey Agency was not submitted within the mandated two-hour window, instead being sent over 21 hours later. Staff interviews indicated misunderstanding of the regulatory reporting timelines.
A facility failed to thoroughly investigate and implement protective measures after a resident-to-resident sexual incident. Staff did not provide targeted monitoring for sexual behaviors or update the care plan to address these behaviors, and there was no evidence of additional staff education on abuse prevention following the event.
A resident's care plan was not updated to address sexual behaviors directed towards others, despite an incident involving inappropriate contact between two residents. The care plan only included interventions for bipolar disorder symptoms and did not address the new behavioral concern, contrary to facility policy requiring care plan revisions after a status change.
The facility did not maintain documentation showing that staff received education on COVID-19 vaccination, were offered information about obtaining the vaccine, or had their vaccination status recorded, as confirmed by staff interviews and the absence of records when requested.
A nurse pre-poured medications into unlabeled cups and stored them in the medication cart, then administered these medications to multiple residents without proper labeling or verification. The nurse also documented medications as given on the MAR before actual administration and transferred pills between unlabeled cups, contrary to facility policy requiring one-at-a-time administration and post-administration documentation.
Staff did not consistently follow infection control protocols, including failure to use required gowns during enteral medication administration, inadequate hand hygiene before and between glove changes during medication administration and wound care, improper handling of wound care supplies, and returning a cigarette from the floor to a resident's possession without hand hygiene. These actions were not in accordance with facility policies and were confirmed through direct observation and staff interviews.
Three residents who had consented to pneumococcal vaccination did not receive the appropriate vaccine, as documented in their medical records. In two cases, no pneumococcal vaccine was administered after consent, and in another, the recommended Prevnar20 was not given despite prior PPSV23 administration. Staff reported limited vaccine documentation and were awaiting access to the state immunization system to update records.
Two residents experienced a lack of dignity when one witnessed the removal of a deceased resident through a populated hallway, causing emotional distress, and another was left waiting in wet clothing after an incontinence episode, leading to frustration and anger. Staff did not follow established privacy protocols or timely incontinence care as outlined in care plans and facility policy.
Staff failed to supervise and document the self-administration of medications for two residents, resulting in unsupervised access to pain pills and a rescue inhaler left at the bedside. Facility policy required RN assessment, documentation, and care plan updates for self-administration, but these steps were not completed or reflected in the residents' records.
A resident's advance directives and code status were not accurately maintained or readily accessible to staff, resulting in conflicting POLST forms and uncertainty among staff regarding the resident's current wishes. Staff relied on electronic records and binders, but inconsistent documentation and lack of up-to-date information led to confusion during care and emergency planning.
Three residents were affected by unclean wheelchairs and unpainted, non-cleanable surfaces in their rooms and bathrooms. Observations showed wheelchairs with caked-on debris and walls with chipped or missing paint, creating unsanitary conditions. Staff interviews revealed that maintenance and cleaning tasks were not completed as required due to prioritization of other duties and lack of time, and maintenance logs showed few repairs had been made.
A resident's care plan was not updated to reflect a change from full code to DNR status as documented in the most recent POLST. Staff reported that care plan updates were assigned during morning meetings, but the care plan continued to show outdated information despite the resident's new DNR election.
Two residents who required assistance with bathing did not receive regular showers as scheduled, resulting in feelings of uncleanliness and dissatisfaction. Observations showed both had oily hair, and records confirmed infrequent bathing over a 30-day period. Staff interviews indicated that CNAs often missed baths due to time constraints, despite facility policy requiring regular assistance with hygiene.
A staff member did not follow provider orders for administering medications through a gastrostomy tube for a resident, failing to check tube placement by auscultation and not using the correct amount of water flushes as ordered. All medications were given together instead of one at a time with appropriate water flushes, contrary to both provider orders and facility policy.
Two residents did not receive medications as ordered, including one who was given midodrine without confirmation of food intake and another who received multiple medications via PEG tube in a single cup with insufficient water flushes. Staff admitted to not following prescriber orders, resulting in a medication error rate of 20%.
A nurse administered both a scheduled dose of long-acting insulin and an additional dose of fast-acting insulin intended for another resident to a single resident, due to distraction and improper labeling of insulin pens. The error resulted in the resident being sent to the ER for continuous glucose monitoring. Environmental factors such as poor lighting and noise contributed to the incident, and the facility's medication administration policies were not followed.
A resident and their representative reported missing personal items, including clothing, after discharge. Despite notifying the facility, no response or investigation was documented, and the required inventory list was not found in the medical record. The facility's grievance log did not reflect the complaint, and staff could not provide the necessary documentation, indicating a failure to follow established policies for inventory and grievance handling.
Two residents experienced cardiac arrest events and expired in the facility due to the lack of staff CPR certification, inadequate training, and missing essential supplies such as Ambu bags and protective barriers on the crash cart. Staff were unclear about their responsibilities, the crash cart was not easily accessible or routinely checked, and there was no process in place to track CPR certifications or ensure emergency supplies were available.
The facility failed to maintain accessible and properly stocked crash carts, resulting in delays in emergency respiratory care for two residents. Staff were unable to locate essential supplies such as Ambu bags and barriers during code situations, and there was no clear responsibility or documentation for checking or restocking crash carts. The facility's assessment and policies did not adequately address respiratory care services, equipment, or staff training related to respiratory emergencies.
The facility did not update its Facility Assessment to reflect the addition of a pulmonary program, omitting key information about respiratory care services, staffing changes, equipment, staff training, and necessary medical supplies. Staff interviews confirmed the program had been in place for about a year, but the assessment failed to address these changes, increasing the risk for residents needing pulmonary care.
The facility did not ensure staff received adequate training on supply locations, ordering procedures, crash cart management, or CPR certification. Multiple staff, including contracted personnel, reported not being shown where supplies were kept, how to order them, or how to restock the crash cart. Some staff had not received CPR training or certification, and there was no clear policy or documentation outlining these requirements.
The facility did not provide required infection prevention and control training to new, existing, and contracted staff, and several staff members were unaware of the Infection Preventionist's identity. The facility had a gap in Infection Preventionist coverage, and staff education on infection control policies and procedures was not conducted as outlined in facility protocols.
Licensed staff administered medications with specific blood pressure and pulse parameters without consistently checking or documenting vital signs, resulting in multiple instances where medications were given outside of ordered parameters for three residents. Staff interviews confirmed a lack of adherence to physician orders and facility policy regarding medication administration.
Three residents received medications outside of physician-ordered parameters, including administration of Midodrine and Atenolol without appropriate blood pressure or pulse checks or despite readings that should have resulted in the medication being held. Staff interviews confirmed knowledge of the requirement to check vital signs prior to administration, but this was not consistently followed or documented.
Staff failed to consistently perform hand hygiene and implement enhanced barrier precautions, with multiple staff members entering and exiting resident rooms, handling medication and meal trays, and providing care without washing hands or using sanitizer. Several staff were unaware of infection prevention protocols or which residents required enhanced precautions, and there was a gap in infection prevention oversight due to staff turnover. Facility records showed limited recent training on infection control.
Two residents with indwelling Foley catheters did not receive proper daily catheter care, resulting in discomfort, foul odors, and visible signs of inadequate hygiene at the catheter site. Staff interviews and record reviews revealed inconsistent performance and documentation of catheter care, with one resident's care not recorded due to a missing physician order. Facility policy required catheter care every shift, but this was not consistently followed.
The facility failed to ensure staff roles were clear and within their scope, leading to inappropriate care planning and medication recommendations. A staff member without clinical qualifications recommended medications, and there was inadequate follow-up on residents leaving AMA. Additionally, behavioral health concerns were poorly documented, and policies against substance use were not enforced.
The facility failed to properly document and communicate the circumstances surrounding AMA discharges for two residents. One resident was not informed of their rights or offered transportation, and APS was not contacted. Another resident's discharge was postponed without clear communication, leading to frustration. Staff interviews revealed inconsistencies in handling AMA discharges, and the facility's policy on AMA discharges was not followed.
The facility failed to complete timely MDS assessments for several residents, with delays in Quarterly, Annual, and Discharge MDS assessments. New MDS coordinators were behind on their tasks and unsure of completion timelines, leading to overdue assessments. A lack of oversight and consistent nursing administration contributed to the issue.
The facility failed to submit MDS information within the required 14 days for several residents due to the inexperience of new MDS coordinators and lack of oversight. Quarterly, Annual, and Discharge MDS assessments were overdue by 10 to 61 days, violating the facility's policy for timely transmission to the CMS system.
The facility's quality assurance committee did not address a high number of AMA discharges, with 21 residents leaving without physician approval or a care plan. A resident reported feeling unsafe, encountering rude staff, and poor food quality, with no follow-up after their AMA discharge.
The facility failed to enforce its smoking policy, allowing a resident to smoke too close to the building and another to keep tobacco in their room. Additionally, two residents with severe cognitive impairment were not properly assessed for smoking supervision, contrary to policy requirements.
The facility failed to inform two residents about the risks and benefits of their psychotropic medications. One resident was unaware of the names, side effects, or benefits of his mood medications, while another resident, who manages her own medical decisions, was not informed about the side effects of her anxiety and depression medications. Consent forms lacked signatures, and the staff member responsible for the forms could not confirm discussions about risks and benefits, nor did he have a clinical background.
The facility failed to accurately code MDS assessments for two residents, omitting psychiatric diagnoses and incorrectly documenting psychotropic medication use. One resident's MDS did not reflect anxiety and depression diagnoses, and another's did not mark any psychiatric diagnoses despite medication use. Staff interviews revealed unawareness of these inaccuracies, contrary to facility policy requiring accuracy attestation.
A facility failed to provide an appropriate discharge plan for a resident, resulting in insufficient documentation and lack of communication with the resident and caregiver. The resident, requiring daily wound care and antibiotics, was initially informed of a discharge date, but later told it could not proceed, causing frustration and consideration of leaving AMA. Staff acknowledged the need for improvement in the discharge process.
A facility failed to provide necessary behavioral health services to a resident with anxiety and major depressive disorder. The resident's last psychological evaluation was over three years ago, and no services were offered during their stay. Staff interviews revealed inadequate documentation and follow-up on behavioral health issues, with concerns about residents' behaviors not being addressed. The facility's policy required behavioral health services, but these were not adequately provided or documented.
A resident with a pressure ulcer requiring a wound vac did not receive proper care, leading to deterioration of the wound. Staff failed to document issues with the wound vac, such as maintaining a seal and drainage amounts. The wound nurse was on leave, and the staff responsible for wound care struggled with documentation and changed orders without proper records. The facility's policy on wound assessments and documentation was not consistently followed.
The facility failed to conduct thorough investigations for multiple abuse and neglect allegations involving residents. Incidents included a CNA allegedly forcing a resident to drink water, a nurse verbally assaulting a resident, and neglect of care resulting in a leaked foley bag. Documentation was incomplete, lacking details such as identities of alleged abusers, interviews, and protective measures. The facility's policy on abuse, neglect, and exploitation was not followed.
The facility failed to report allegations of abuse within the required 24-hour timeframe for two residents. One resident complained of being verbally assaulted by a nurse, and another was involved in a verbal altercation with a staff member, leading to police involvement. Both incidents were reported late to the State Survey Agency, contrary to the facility's policy requiring immediate notification.
Failure to Monitor and Document Nutrition and Hydration Status
Penalty
Summary
Facility nursing staff failed to obtain weekly weights and did not recognize severe weight loss in one resident, despite physician orders to monitor weight weekly and reweigh if there was a significant change. The resident experienced a 14-pound weight loss over a short period, with no weight documented for three weeks. Staff interviews revealed that the resident often refused weights, and when finally weighed, a significant decline was noted. The resident also had poor dentition, a dental infection, and was experiencing decreased appetite, nausea, and loose stools, all of which contributed to poor intake. Staff were not consistently monitoring or documenting food and fluid intake, and there was confusion about responsibilities for monitoring hydration and nutrition. Additionally, the facility failed to ensure that residents were monitored and tracked for maintenance of proper hydration status. Multiple residents were hospitalized with conditions related to dehydration, including acute renal failure, hyponatremia, and hypovolemia. Staff interviews indicated that hydration status was not routinely tracked or monitored unless residents showed overt signs of dehydration. Documentation of fluid intake was inconsistent or missing, and some staff were unaware of the need to monitor for the effects of diuretic use beyond checking for edema. The facility's own policy required systematic assessment and monitoring of hydration status, but this was not consistently implemented. Staff reported that hydration tracking had been removed from the charting system for most residents, and only a few had active hydration monitoring. There was a lack of clear communication and accountability regarding who was responsible for monitoring and documenting hydration and nutritional intake, leading to missed signs of decline and delayed interventions for residents at risk.
Failure to Ensure Nursing Staff Competency in Resident Assessment and Documentation
Penalty
Summary
Nursing staff failed to demonstrate appropriate competencies in assessing, monitoring, and recognizing clinical changes in a resident who experienced ongoing clinical decline. The resident, an elderly female, was admitted with multiple health concerns including a dental infection, use of a diuretic for congestive heart failure, and was at risk for weight loss. Over the course of her stay, she developed recurrent vomiting, hypotension, altered mental status, and ultimately required hospitalization for aspiration pneumonia, severe hyperkalemia, acute renal failure, and sepsis. Staff interviews and record reviews revealed that changes in the resident’s condition, such as increased confusion, falls, and weakness, were not consistently documented or communicated among the care team. Daily skilled nursing assessments were not completed as required, and there was a lack of clear documentation regarding the onset and progression of the resident’s decline. Further review showed that vital signs, intake and output, and weights were not consistently recorded in the medical record, despite physician orders and facility policies requiring such documentation. The resident experienced a significant, unmonitored weight loss and there was no evidence that the dietitian or physician was notified of her declining intake. Staff members reported that they relied on their own assessment and critical thinking skills due to the absence of clinical pathways, and that training on assessment skills was primarily delivered through computer modules or infrequent staff meetings. Additionally, the facility’s electronic health record system had issues with hydration tracking, and some documentation was deleted or not entered, further impeding the ability to monitor the resident’s status. The facility’s policies required accurate, complete, and timely documentation of assessments, observations, and services provided, as well as systematic approaches to optimize hydration status. However, these protocols were not followed for this resident. Staff interviews confirmed that documentation of the resident’s change in condition, interventions, and communication with providers was lacking or missing entirely. The failure to document and respond appropriately to the resident’s clinical changes resulted in her developing severe complications and requiring hospitalization.
Failure to Ensure Resident Dignity and Respect Due to Deficient Staff Attitudes and Communication
Penalty
Summary
The facility failed to ensure that residents were treated with dignity, respect, and a customer service approach, as evidenced by multiple resident and family interviews, observations, and grievance reviews. Residents reported that staff often did not address all their needs during care, such as not assisting with oral hygiene or washing in the morning, and sometimes made residents feel like they were a burden. Several residents described staff as having poor attitudes, lacking caring mannerisms, and being dismissive or even mocking toward residents. One resident recounted witnessing a CNA cussing at a hospice patient in pain, while others described staff as being loud, using inappropriate language, and making residents feel disrespected or uncared for. Grievance records further documented concerns about staff approach, including staff refusing reasonable food substitutions, failing to provide timely incontinence care, and making racially insensitive or inappropriate remarks. Residents expressed a lack of confidence in the grievance process and reported fear of retaliation if they voiced concerns. Family members also noted that staff were not invested in resident care, leading to increased stress and concerns about the quality of care provided. These findings collectively demonstrate a pattern of deficient staff behavior and communication that compromised residents' rights to dignity, self-determination, and respectful treatment.
Failure to Consistently Provide and Document Scheduled Showers
Penalty
Summary
The facility failed to consistently provide and document scheduled showers for four of twelve sampled residents. Interviews and record reviews revealed that one resident's hygienic needs, including showering, shaving, hair trimming, and fingernail clipping, were not met frequently enough, resulting in a family member performing these tasks. Documentation showed gaps of up to seven days without a recorded shower or refusal, despite a set schedule. Another resident had only one documented shower refusal since admission, with no other records of completed or refused showers, and inconsistencies were found between paper and electronic documentation. Staff interviews confirmed issues with documentation practices, including reliance on paper records and double documentation, which contributed to the inconsistencies. Two additional residents expressed concerns about missed scheduled showers, with one reporting being left unattended in the shower room for 45 minutes without access to a pull cord, despite being wheelchair-bound. Review of the shower schedule and electronic health records showed significant gaps between documented showers, sometimes up to 14 days. Facility policy required showers to be provided per schedule or resident request, with documentation on both paper and electronic systems, and a specific process for documenting refusals. However, these protocols were not consistently followed, leading to incomplete records and unmet resident care needs.
Failure to Ensure Accessible and Functional Call Light System
Penalty
Summary
The facility failed to ensure that call lights were consistently available, accessible, and functional for multiple residents, resulting in unmet needs and safety concerns. Observations revealed that one resident, identified as a fall risk, was unable to locate his call light, which was draped over a fall mat and lacked a clip for proper placement. Staff were uncertain about the correct placement of call lights for residents with dementia. In the shower room, a wheelchair-bound resident was left unattended for an extended period without access to a reachable call light, as the pull cord was missing and the call light station was obstructed by shower chairs. Staff confirmed that residents should not be left alone in the shower room, and the lack of accessible call lights posed a safety risk. Interviews with several residents indicated prolonged wait times for call light responses, with some reporting waits of up to four hours or having to repeatedly request assistance. Residents described situations where call lights were not working, had to be pulled from the wall, or were not reachable due to their physical limitations. Staff interviews and facility work order records showed that multiple call lights required repairs within a single month, and some staff expressed concern about the frequency of these issues. Facility grievance records further documented complaints about non-functional call lights and delayed responses, with some residents' needs not being met even after staff responded to the call light.
Failure to Maintain Clean and Homelike Resident Rooms
Penalty
Summary
The facility failed to maintain a clean and homelike environment for three of twelve sampled residents, as evidenced by multiple observations and interviews. One resident's room had visible dirt and pieces of paper under the bed, with staff and the resident confirming that garbage was often present and that cleaning under beds was not routinely performed. Another resident's room had visible dirt near the wheelchair area, and the resident noted inconsistent cleaning depending on the staff member, while a staff member admitted to only cleaning as needed. A third resident had oxygen tubing ear protectors and a green piece of garbage under the bed on consecutive days. Facility cleaning records were incomplete or missing for the relevant dates, further indicating lapses in routine cleaning practices.
Failure to Provide Assistance with Oral Care for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident who required assistance with activities of daily living (ADLs), specifically oral care, did not receive help with teeth brushing throughout the day. The resident reported on multiple occasions that he had not brushed his teeth and that staff had not assisted him, despite a visible reminder in his room indicating the need for oral care as recommended by speech therapy. Staff interviews confirmed inconsistent provision of ADL care, with some CNAs performing all required tasks and others not. The facility's policy states that residents unable to perform ADLs should receive necessary services to maintain personal and oral hygiene, but this was not followed in the resident's case.
Failure to Follow Physician Wound Orders and Proper Hand Hygiene
Penalty
Summary
A deficiency occurred when a staff member, who was not wound certified, failed to follow physician orders for wound care for one resident. During a dressing change, the staff member applied calcium alginate to the resident's wound, despite the physician's order specifying to cleanse with wound cleanser and apply a collagen pad secured with a dry dressing. The staff member stated they added the calcium alginate because the wound had not been healing and believed it would help with drainage, even though this was not part of the prescribed treatment. Additionally, the staff member did not perform proper hand hygiene after removing the old dressing and before applying the new one. The facility's policy required wound treatments to be provided in accordance with physician orders.
Failure to Prevent Accidents and Ensure Adequate Supervision
Penalty
Summary
The facility failed to ensure that a shower room was free from accident hazards and provided adequate supervision, as evidenced by a wheelchair-bound resident being left alone in the shower room for 45 minutes without access to a call light pull cord. The call light station was not only missing the required pull cord but was also out of reach due to obstructing shower chairs, creating a hazardous environment. Staff confirmed that residents should not be left unattended in the shower room and that the lack of call light accessibility was unsafe. Another resident, identified as having a high risk for falls, did not consistently have fall prevention interventions in place. Observations revealed that the resident's fall mat was folded and not positioned on the floor as required, and the call light was not within reach, with its button hidden behind the mat. The resident was observed attempting to get out of bed without assistance, and the bed was found to be unlocked on multiple occasions. Staff interviews indicated that interventions such as ensuring the call light was within reach and the fall mat was in place were not always followed, and concerns about the adequacy and consistency of fall prevention measures were raised by both staff and family. A third resident experienced multiple falls, some resulting in head injuries, with documentation indicating possible causes such as orthostatic hypotension, dehydration, and a potential seizure. Despite these incidents, observations showed that the resident did not have water readily available at the bedside and was not using prescribed oxygen. The facility's fall prevention policy required individualized interventions and routine rounding, but the lack of consistent implementation of these measures contributed to the resident's repeated falls and injuries.
Failure to Provide Necessary Dental Services for Resident with Dental Abscess
Penalty
Summary
The facility failed to provide necessary dental services for a resident who had a documented dental abscess and was awaiting Medicaid approval for insurance coverage. Upon admission, the resident had a known dental infection and was prescribed antibiotics, with a follow-up dental appointment scheduled prior to hospital discharge. Staff interviews and record reviews revealed that the social services assessment identified dental needs, but no dental visit request was filed, and staff were unaware of the abscessed tooth. When the dental office contacted the facility regarding payment for the scheduled extraction, staff found that the resident lacked dental insurance and was unable to pay the $1200 fee. The appointment was subsequently canceled after discussing the cost with the resident, and staff were not aware of available facility resources or the resident's pending Medicaid status. Further review of the resident's records showed ongoing dental infection, difficulty chewing, and significant weight loss since admission. The care plan included a focus on dental care, but no arrangements were made for the necessary procedure due to the perceived lack of payment options. Communication breakdowns between nursing, social services, and the business office contributed to the failure to secure dental care, despite the resident's Medicaid approval being effective shortly after admission. The deficiency resulted in the resident experiencing pain, difficulty eating, and severe weight loss.
Delayed COVID-19 Vaccination and Documentation Failures During Outbreak
Penalty
Summary
The facility failed to provide COVID-19 vaccines in a timely manner to eligible residents, specifically two residents who subsequently contracted COVID-19. One resident reported being asked about receiving the vaccine approximately a month prior but had not received it despite expressing a desire to be vaccinated. Another resident's family member stated they had repeatedly requested the vaccine for the resident, but no consent or declination form was provided, and the vaccine was not administered. The family member also reported a lack of communication from the facility during a COVID-19 outbreak, leading them to contact the health department for information. Staff interviews revealed that vaccines were not administered because the primary physician recommended waiting until residents were off isolation, and the facility did not have COVID-19 vaccines on hand due to unavailability from the pharmacy. Documentation showed that one resident was offered and received the vaccine, while another had only been asked about it but had not received it. The facility was unable to provide vaccination or declination documentation for one resident. The COVID-19 outbreak began before vaccines were available at the facility, and staff reported that a significant portion of the building had been offered the vaccine only after the outbreak had started.
Failure to Timely Report Suspected Sexual Abuse Incident
Penalty
Summary
The facility failed to submit an initial report to the State Survey Agency within the required two-hour timeframe following a suspected resident-to-resident sexual abuse incident involving two residents. According to the incident documentation, one resident was found in another resident's room by two staff members; the second resident was lying in bed with his brief undone while the first resident had her hand on his penis. The incident occurred at 1:30 a.m., but the report was not received by the State Survey Agency until over 21 hours later. Staff interviews revealed confusion regarding the reporting requirements, with one staff member incorrectly believing that only incidents involving serious bodily injury needed to be reported within two hours, and others could be reported within 24 hours.
Failure to Investigate and Prevent Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation and implement necessary protective measures following a resident-to-resident sexual incident involving two residents. On the date of the incident, one resident was found in another resident's room with her hand on his penis, and the second resident's brief was undone. Both residents were assessed for injury, and the incident was reported to the appropriate staff. However, the facility's investigation documents did not include evidence of staff education for abuse prevention related to the incident, nor did they show that monitoring for sexual behaviors was implemented for the initiating resident. Additionally, although staff were reportedly charting behavior monitoring for the initiating resident, there was no indication that sexual behaviors were specifically identified or targeted for ongoing monitoring. The care plan for the initiating resident referenced behavioral issues such as shouting and wandering, but did not address sexual behaviors, focus areas, goals, or interventions related to the incident. The most recent documented staff in-service training on abuse/neglect occurred three weeks prior to the incident, with no documentation of additional training provided after the event.
Failure to Update Care Plan for Sexual Behaviors
Penalty
Summary
The facility failed to update a resident's care plan to address sexual behaviors directed towards others, which could constitute abuse. Specifically, a review of a facility-reported incident showed that one resident was found in another resident's room, with the second resident's hand on the first resident's genitals. Despite this incident, the comprehensive care plan for the resident involved did not include any focus area, goals, or interventions related to sexual behaviors or the potential for sexual abuse towards others. The care plan only addressed manifestations of bipolar disorder, such as shouting and wandering, but omitted any mention of sexual behaviors. During an interview, a staff member confirmed that the resident's sexual behaviors had not been added to the care plan and acknowledged that such behaviors should have been care planned. Facility policies reviewed indicated that care plans are to be developed and revised upon a resident's status change, but this process was not followed in this case. The deficiency was identified through both interview and record review, with documentation supporting that the care plan was not updated as required.
Failure to Document Staff COVID-19 Vaccination Education and Status
Penalty
Summary
The facility failed to maintain required documentation regarding COVID-19 vaccination for staff members. Specifically, there was no evidence that staff had been provided education about the benefits and potential risks of the COVID-19 vaccine, nor that they had been offered information on obtaining the vaccine. During interviews, staff members confirmed the absence of documentation related to staff COVID-19 vaccination status or declination. Additionally, when a written request was made for documentation on five randomly selected staff members, the facility was unable to provide any records prior to the survey exit. Review of the facility's own policy indicated that such documentation was required, including education, offering of the vaccine, and recording of vaccination status.
Failure to Follow Professional Standards During Medication Administration
Penalty
Summary
Staff member Z failed to follow professional standards during medication administration by pre-pouring medications into unlabeled cups and storing them in the medication cart. During multiple observations, staff member Z administered medications to several residents from these unlabeled cups, stating she knew which medications belonged to which residents but could not find the residents at the time. She also admitted to marking medications as given on the Medication Administration Record (MAR) before actually administering them, acknowledging that this was not the correct procedure. On one occasion, staff member Z transferred pills from one unlabeled cup to another prior to administration, and at the end of her medication pass, there were still three unlabeled cups remaining in the cart for which she was unsure of the intended recipients. The facility's policy requires that medications be administered one at a time, observed for consumption, and signed off on the MAR only after administration. Staff member Z's actions, including pre-pouring, using unlabeled cups, and documenting administration before actual delivery, were inconsistent with these professional standards and facility policy. These practices were observed for nine residents during the medication pass, with staff member Z expressing confusion about the process and the identity of the medications in some cups.
Failure to Follow Infection Control Protocols During Medication Administration, Wound Care, and Resident Assistance
Penalty
Summary
Staff failed to adhere to infection prevention and control protocols in several instances involving multiple residents. During medication administration via a PEG tube for a resident under Enhanced Barrier Precautions (EBP), a staff member donned gloves but did not wear a protective gown as required for high-contact activities involving device care. The staff member later acknowledged that a gown should have been worn during the procedure. Facility policy specified that EBP includes the use of gowns and gloves during care activities such as feeding tube management. Hand hygiene practices were not consistently followed by staff during medication administration and wound care. One staff member did not sanitize hands between glove changes while administering medications via PEG tube, and another did not perform hand hygiene before donning gloves or between glove changes during wound care for a resident with multiple wounds. Additional staff members failed to perform hand hygiene before preparing or administering medications to several residents. Facility policies required hand hygiene before donning gloves and before medication administration, but these were not followed as observed. In wound care, a staff member placed supplies directly on unclean surfaces without protective barriers and used scissors stored in an unclean pocket to cut bandages, which were then applied to a resident's wound. Additionally, another staff member picked up a cigarette from the floor and returned it to a resident's cigarette box without performing hand hygiene. These actions were contrary to infection control procedures and facility policies, as confirmed by staff interviews and policy reviews.
Failure to Administer Pneumococcal Vaccines After Consent
Penalty
Summary
The facility failed to ensure that residents who had been screened and provided consent for pneumococcal immunizations actually received the vaccine. Specifically, three residents who had signed informed consent forms for the pneumococcal vaccine did not have documentation of receiving the vaccine in their electronic health records. For two of these residents, there was no record of the pneumococcal vaccine being administered after consent was obtained. For the third resident, although a previous dose of PPSV23 was documented, the recommended Prevnar20 vaccine had not been administered as per current CDC guidelines. During interviews, staff members reported that they had recently started working at the facility and noted that there was limited documentation available regarding resident vaccinations. They also indicated that they were waiting for access to the state immunization information system to update and verify the facility's vaccine records. The facility's policy requires a signed consent form prior to vaccine administration and specifies that the type of pneumococcal vaccine offered should align with CDC recommendations, but these procedures were not followed for the residents in question.
Failure to Maintain Resident Dignity During Postmortem Care and Incontinence Episode
Penalty
Summary
The facility failed to maintain resident dignity in two separate incidents. In the first incident, after a resident's death, two unidentified individuals removed the deceased resident on a stretcher covered with a blanket through a hallway where other residents and visitors were present. This action was observed by another resident, who expressed sadness and distress at witnessing the event. Staff later confirmed that the usual practice is to clear the hallway and use the closest exit to maintain privacy, as outlined in the facility's post-mortem care policy, but this was not followed in this instance. In the second incident, a resident who experienced an episode of incontinence was left waiting in wet clothing for assistance. The resident had activated the call light and reported that staff entered the room but only told him they would return, causing him frustration and anger. The resident's care plan indicated a need for dependent assistance by two staff for toileting and a check and change schedule every two hours, but the electronic medical record did not reflect this schedule. Staff confirmed the resident should be checked and changed every two hours.
Failure to Supervise and Document Resident Self-Administration of Medications
Penalty
Summary
Facility staff failed to properly supervise the self-administration of medications for two residents. One resident was observed with two blue pills, identified as Ibuprofen and Tramadol, left on the bedside table in a plastic medicine cup without staff present. The resident reported that some nurses would leave medications for later self-administration, while others would not. Another resident had a metered-dose inhaler left on the bedside table, which she stated was her rescue inhaler that she rarely used but preferred to keep in her room. In both cases, there was no staff supervision at the time the medications were accessible to the residents. Interviews with staff revealed inconsistent practices regarding medication administration and storage. Staff members indicated that facility policy required an RN assessment and documentation before allowing self-administration of medications, and that the MAR should reflect such authorization. However, there were no self-administration assessments or care plan documentation for the two residents involved. The facility's policy also required that medications not be left at the bedside unless authorized and that storage arrangements be documented in the care plan, which was not done for these residents.
Failure to Maintain Accurate and Accessible Advance Directives
Penalty
Summary
The facility failed to maintain an effective process to ensure that the most current and accurate code status and advance directives for a resident were readily known and available to staff in the event of an emergency. Multiple staff interviews revealed inconsistent knowledge about the location and content of the resident's advance directives and POLST forms. Staff reported that advance directives were requested on admission and updated during care conferences, with copies uploaded to the electronic medical record. However, it was discovered that a resident had completed multiple POLST forms with conflicting instructions—one indicating full code with brief CPR and another indicating DNR—without the facility having all relevant documents on file or clearly identifying the most current directive. The resident's son also indicated that advance directives had been completed and should be present in the resident's room, but these were not on file with the facility until staff made copies after the fact. Record review showed two different POLSTs uploaded in the electronic medical record, with no other advance directives present. The care profile listed the resident as full code/full treatment, while the physician's orders reflected an active order for full code and full treatment, with no other orders for advance directives or code status documented. Staff interviews indicated reliance on the electronic medical record and binders at the nurses' station for code status information, but the presence of conflicting documents and lack of clear, up-to-date information created confusion about the resident's actual wishes. The deficiency was identified for one resident out of a sample of thirty.
Failure to Maintain Clean and Homelike Environment for Residents
Penalty
Summary
The facility failed to maintain a clean, safe, and homelike environment for three sampled residents, as evidenced by multiple observations of unclean wheelchairs and unpainted, non-cleanable surfaces in resident rooms and bathrooms. Specifically, paint was chipped or missing on walls near beds and sinks, exposing drywall and creating surfaces that could not be properly cleaned. Residents expressed dissatisfaction with the appearance of their environment, noting that the condition of the walls was bothersome. Additionally, wheelchairs used by the residents were observed to have accumulated debris, including caked-on white and brown substances on the seats, footrests, and metal parts, which were not cleaned between observations on consecutive days. Interviews with staff revealed that maintenance requests for paint repairs were deprioritized in favor of fire life safety issues, and that routine cleaning of wheelchairs was assigned to night shift CNAs, who reported insufficient time to complete these tasks. Review of maintenance logs indicated a lack of documented work orders for paint repairs in the current year and minimal touch-ups in the previous year. The facility's own policy required routine inspections and immediate correction of identified issues, but these procedures were not followed, resulting in the observed deficiencies.
Failure to Update Care Plan After Code Status Change
Penalty
Summary
The facility failed to ensure the accuracy of a resident's care plan following a change in code status. Specifically, a resident's care plan initially indicated full code status based on the POLST in the referral packet, with interventions to request and review advance directives upon admission and at least quarterly. However, the most recent POLST, signed by the provider, indicated the resident had elected Do Not Resuscitate (DNR) status. Staff interviews revealed that care plan updates were typically handled by the affected department and assigned during morning meetings if needed, but the care plan was not updated to reflect the resident's current DNR status as documented in the latest POLST.
Failure to Provide Regular Showers to Dependent Residents
Penalty
Summary
Facility staff failed to provide regular showers to two residents who required assistance with bathing, as evidenced by observations and interviews. One resident, who had been in the facility for approximately seven months, reported that baths had not been consistent and expressed dissatisfaction with the use of dry shampoo as a substitute. Observation revealed the resident's hair was oily and stringy, and a review of the electronic medical record showed only two baths were provided in a 30-day period. The resident's care plan indicated a need for set-up assistance with showers or bathing. Another resident was observed with oily, matted hair and reported not receiving regular baths as scheduled, which made her feel unclean. This resident was supposed to receive baths twice weekly but had only one documented bath in the same 30-day period. Her care plan required limited to extensive assistance with showering, depending on her energy and fatigue levels. A staff member confirmed that CNAs were responsible for baths but often lacked time to complete them, resulting in missed showers. Facility policy required staff to assist residents with bathing according to requests or the facility schedule.
Failure to Follow Provider Orders for Medication Administration via Feeding Tube
Penalty
Summary
Staff member N failed to follow provider orders during the administration of medications via a gastrostomy tube (GT) for a resident. Specifically, the staff member did not check for correct placement of the GT by auscultation prior to administering medications, as required by the provider's orders. Instead, the staff member flushed the tube with 10 ml of water, administered all medications mixed together, and then flushed the tube again with 10 ml of water, using a total of 30 ml of water. The provider's orders specified that medications should be given one at a time with a 10 ml water flush between each medication, and that the tube should be flushed with 30 ml of water before and after medication administration, totaling 110 ml of water per administration. During an interview, the staff member acknowledged that the method used did not match the provider's written orders and that the total volume of water used was incorrect. Facility policy also required verification of tube placement before administering medications, which was not performed during the observed medication pass. The resident involved had an active order for medication administration via GT, and the deficiency was identified through direct observation, interview, and record review.
Medication Administration Errors Result in 20% Error Rate
Penalty
Summary
The facility failed to properly administer medications according to prescriber orders for two residents, resulting in a medication error rate of 20%. In one instance, a staff member administered midodrine 2.5 mg to a resident without confirming if the resident had eaten, despite the medication order specifying administration with meals. The staff member admitted to not knowing whether the resident had eaten and stated that nurses had told her it was acceptable to give the medication without food. Review of the facility's medication administration policy confirmed that medications are to be given as ordered by the physician, including at the right time. In another case, a staff member administered multiple medications via PEG tube to a resident by combining them in one cup and using only 30 ml of water, contrary to the provider's order, which required medications to be given one at a time with 10 ml water flush between each, and a total of 110 ml water per administration. The staff member acknowledged that she routinely administered the medications in this manner and did not follow the specific order for water flushes. These actions directly contributed to the facility's medication error rate exceeding the acceptable threshold.
Significant Medication Error: Insulin Administered to Wrong Resident
Penalty
Summary
A significant medication error occurred when a nurse administered both a scheduled dose of long-acting insulin and an additional dose of fast-acting insulin intended for another resident to a single resident. The nurse was distracted and brought two pre-filled insulin pens into the resident's room, one containing 18 units of long-acting insulin for the resident and the other containing 42 units of fast-acting insulin for the roommate. Both doses were given to the same resident, which was not in accordance with physician's orders or the facility's medication administration policy. The error was realized after administration, and the resident required immediate transfer to the emergency room for continuous glucose monitoring. Interviews and record reviews revealed that the insulin pens were not properly labeled, with labels only on the lids and not on the bodies of the pens. Contributing environmental factors included poor lighting and noise during the medication pass. The nurse involved had received initial training on medication management and injections, but direct observation of competency was not documented. Other staff members reported not receiving specific education regarding the incident at the time, and the facility's policies required adherence to the six rights of medication administration, which were not followed in this case.
Failure to Document and Investigate Resident Grievance Regarding Missing Personal Items
Penalty
Summary
The facility failed to maintain an accurate inventory of a resident's personal items and did not properly identify or investigate a grievance related to missing clothing following the resident's discharge. Interviews with staff and the resident's representatives revealed that concerns about missing items, including a gray hooded jacket, pajama sets, shoes, shirts, and pants, were communicated to the facility, but no response was provided. The facility's grievance log did not document any grievance related to the missing clothing, and the resident's electronic medical record lacked an inventory list of personal items. Despite requests, the facility was unable to provide documentation of the inventory for the resident in question. Facility policy requires that all resident personal items be inventoried at admission, with documentation retained in the medical record, and that inventories be reviewed and signed off at discharge. Additionally, the grievance policy mandates that grievances be tracked, investigated, and concluded with a written decision. In this case, these procedures were not followed, as evidenced by the absence of inventory documentation and the lack of a recorded or investigated grievance regarding the missing items.
Failure to Ensure CPR Training, Certification, and Emergency Supplies
Penalty
Summary
The facility failed to ensure that nursing staff possessed the necessary skills and training to perform CPR, as well as to maintain a process for identifying and tracking staff CPR certifications. Two residents, both identified as full code with active physician orders for resuscitation, experienced cardiac arrest events in the facility. During these emergencies, staff were unable to provide high-quality CPR due to missing essential supplies, such as Ambu bags and protective barriers, on the crash cart. Staff interviews revealed that some nurses were not CPR certified, had not been offered training, and did not know who was responsible for checking or stocking the crash cart. In both incidents, the crash cart was not easily accessible, and staff had to search for necessary respiratory supplies during the code events, resulting in delays in care. The crash cart was found to be located in a difficult-to-access area, sometimes blocked by other equipment, and was not routinely checked or restocked. Staff reported that there was no designated person responsible for ordering or stocking emergency supplies, and requests for additional supplies were not fulfilled in a timely manner. Documentation showed that Ambu bags were ordered only after the first code event, and supplies did not arrive before the second code event occurred. The facility's policies stated that staff would maintain current CPR certification and that crash carts would be routinely checked and stocked with critical supplies. However, interviews and record reviews indicated that these policies were not followed. Staff were unclear about their responsibilities regarding emergency preparedness, and there was no system in place to ensure that staff were trained or that crash carts were properly maintained. The facility assessment also failed to identify the need for emergency respiratory supplies.
Failure to Ensure Readily Available Respiratory Supplies During Emergencies
Penalty
Summary
The facility failed to ensure that proper respiratory supplies were readily available and accessible during emergencies, resulting in delays in care for two residents. Observations revealed that crash carts were not easily accessible, with one cart wedged between a treatment cart and a wall, and another blocked by equipment in a utility room. Staff interviews confirmed that essential supplies such as Ambu bags and barriers were missing from the crash carts during code situations. Multiple staff members reported having to leave the resident's room to search for necessary respiratory equipment, causing further delays in providing life-saving interventions. Staff members consistently stated they did not know who was responsible for checking or stocking the crash carts, and there was no documentation of regular crash cart checks or supply inventories. During at least two separate code events, staff were unable to immediately locate Ambu bags or respiratory barriers, and in one instance, a staff member had to use a personal barrier due to the lack of available supplies. The lack of clear responsibility and oversight for maintaining emergency equipment contributed to the deficiency. A review of the facility's assessment and policies showed that respiratory care and services, including the Pulmonary Program, were not adequately addressed. The assessment did not include information on the types of respiratory care provided, changes in staffing, equipment needs, or staff training and competencies related to respiratory care. Additionally, the medical supplies section failed to address emergency respiratory supplies such as Ambu bags, CPAP, or BIPAP equipment, further indicating gaps in preparedness for respiratory emergencies.
Facility Assessment Not Updated for Pulmonary Program Implementation
Penalty
Summary
The facility failed to review and update its Facility Assessment when a new pulmonary program was planned and implemented. The assessment, dated 1/7/25, did not include any information regarding respiratory care and services, the addition of a pulmonary program, changes in staffing related to the program, necessary equipment for participating residents, staff training or competencies for the program, or medical supplies such as CPAP, BIPAP, or emergency respiratory supplies like Ambu bags. This omission was identified through record review and interviews with staff, who confirmed the pulmonary program had been in place for about a year and that respiratory therapists had recently started working in the facility. Staff interviews revealed that the administrator was unsure why the pulmonary program was not included in the facility assessment, despite being in the position when the program was implemented. Another staff member described the ongoing development of the respiratory program, including recruitment of respiratory therapists and the program's intended benefits for residents. However, this staff member was not involved in the facility assessment process. The lack of updates to the facility assessment increased the risk for negative outcomes for residents requiring pulmonary care, and a negative outcome did occur, as cited in other deficient practice areas.
Failure to Provide Effective Staff Training on Supplies, Crash Cart, and CPR
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for new and existing staff, including contracted staff, as evidenced by multiple staff interviews and record reviews. Several staff members reported not receiving training on the location of supplies, supply ordering procedures, the contents and management of the crash cart, and CPR certification. Staff members indicated they were not shown where supplies were kept, how to order them, or how to document supply needs. In emergency situations, staff were unable to quickly locate necessary equipment such as Ambu bags, and there was confusion regarding the stocking and checking of the crash cart. Some staff had not received CPR training or certification during their employment, and there was no clear documentation or policy outlining these training requirements. The facility's employee handbook provided only general statements about orientation and in-service training, without specific guidance or policies related to the identified deficiencies. Staff interviews revealed a lack of designated responsibility for stocking supplies and the crash cart, and inconsistent knowledge among staff about procedures for ensuring supplies and emergency equipment were available and properly maintained. The absence of a structured and documented training program contributed to staff being unprepared to perform essential duties, particularly in emergency situations.
Failure to Train Staff on Infection Prevention and Control Program
Penalty
Summary
The facility failed to ensure that new staff, existing staff, and contracted staff received training on the infection prevention and control program, including written standards, policies, and procedures. Multiple staff members, including newly hired and contracted personnel, reported during interviews that they had not received any education on infection prevention or hand hygiene policies and procedures. Additionally, these staff members were unaware of the identity of the Infection Preventionist. Further interviews revealed that the facility had not had an Infection Preventionist since the end of November 2024, and the new Infection Preventionist only started on January 21, 2025. Review of the facility's Infection Prevention and Control Program document indicated that all staff were required to receive training relevant to their roles, but this was not being implemented as described.
Failure to Follow Physician Orders and Medication Administration Parameters
Penalty
Summary
The facility failed to adhere to professional standards of practice by administering medications contrary to physician orders for three residents. For one resident, Midodrine was given 20 times despite blood pressure readings outside the ordered parameters, which specified the medication should be held if systolic blood pressure exceeded 120 or diastolic exceeded 60, and the provider should be notified if the medication was held. Another resident received Midodrine 13 times when their blood pressure was outside the prescribed limits. In both cases, staff interviews confirmed that vital signs should be checked immediately prior to administration and that medications with parameters should not be given if those parameters are not met. A third resident was administered Atenolol 15 times without documentation of blood pressure or pulse prior to administration, despite orders to hold the medication if blood pressure was below 100/60 or heart rate below 60. Staff interviews revealed a lack of adherence to the requirement to obtain and record vital signs before administering medications with specific parameters. Facility policy also required that medications be administered according to physician orders and professional standards, including obtaining and recording vital signs when applicable.
Failure to Follow Physician-Ordered Medication Parameters
Penalty
Summary
The facility failed to properly administer medications according to physician-ordered parameters for three residents. For one resident with orthostatic hypertension, Midodrine HCL was administered multiple times when blood pressure readings were outside the specified parameters, contrary to the physician's order to hold the medication if systolic blood pressure exceeded 120 or diastolic exceeded 60. Another resident with hypotension also received Midodrine HCL on several occasions when blood pressure readings were above the ordered hold parameters. In both cases, the medication was given despite documented blood pressure readings that should have resulted in the medication being withheld. Additionally, a third resident prescribed Atenolol for essential hypertension received the medication on numerous occasions without any documentation of blood pressure or pulse prior to administration, despite orders to hold the medication if blood pressure was below 100/60 or heart rate below 60. Interviews with multiple staff members confirmed that vital signs should be checked immediately before administering medications with such parameters, and that this practice is part of the standard medication administration protocol. Facility policy also requires adherence to the six rights of medication administration, including proper documentation.
Failure to Adhere to Infection Control and Hand Hygiene Practices
Penalty
Summary
Facility staff failed to adhere to infection prevention and control practices, specifically regarding hand hygiene and the implementation of enhanced barrier precautions. Multiple staff members were observed not performing hand hygiene before or after resident contact, after touching potentially contaminated surfaces, or when moving between resident rooms. For example, one staff member handled medication cups and a computer before administering medications to a resident without performing hand hygiene, while another staff member entered and exited several resident rooms, handled meal trays, and assisted with meals without washing hands or using sanitizer. Staff members also demonstrated a lack of awareness and training regarding infection prevention protocols. Several staff could not recall the last time they received infection prevention or hand hygiene training, and some were unaware of which residents required enhanced barrier precautions. In one instance, a staff member was not aware that a resident with a suprapubic catheter and tube feeding should have been on enhanced barrier precautions, and there was no signage or personal protective equipment available for that resident. The facility had a lapse in infection prevention oversight, as the previous Infection Preventionist had resigned and there was a gap before a new person assumed the role. During this period, monitoring and education on infection control practices were not consistently provided. Review of facility documents showed that only a limited number of staff had attended recent infection control in-services, and the infection control policy required hand hygiene and proper use of enhanced barrier precautions, which were not being followed in practice.
Failure to Provide Proper Foley Catheter Care and Documentation
Penalty
Summary
The facility failed to provide proper daily indwelling Foley catheter care to two residents, resulting in resident discomfort and the presence of foul urine odors. Observations revealed that both residents had indwelling Foley catheters with red penile meatus and a crusty, solid-like material near the catheter insertion site. One resident reported pain at the catheter site, while the other stated that it had been a couple of days since anyone had performed peri-care or cleaned the catheter. Both residents' rooms had strong urine odors, and staff interviews confirmed that catheter care was not consistently performed as required. Further review showed that documentation of catheter care was lacking, with one resident's catheter care not recorded in the medication administration record due to a missing physician order. Staff interviews indicated that while catheter care was supposed to be performed every shift and documented, there was a reliance on CNAs to complete the care without consistent verification by nursing staff. The facility's policy required catheter care every shift, but this was not followed, leading to the observed deficiencies.
Deficiencies in Staff Role Clarity and Resident Care Follow-Up
Penalty
Summary
The facility failed to ensure that staff members' job duties were current and accurately reflected their scope of practice. Specifically, a social services note in a resident's chart indicated that a staff member was involved in care planning and medication dispensing, which was outside their job description. Interviews revealed that the staff member did not have the authority to hire or fire staff, orient new employees, or provide leadership training, despite these responsibilities being listed in their job duties. Additionally, there was a lack of completed performance evaluations and competency assessments for the staff member. The facility also failed to ensure that staff members were practicing within their scope of practice. A staff member admitted to assessing residents and recommending psychotropic medications, which was not within their professional scope. Another staff member, without a clinical background, was involved in assessing behavioral health concerns and recommending medications, which was inappropriate. This was evidenced by a social services note recommending antidepressants and anxiety medications for a resident, despite the staff member's lack of clinical qualifications. Furthermore, the facility did not adequately follow up on residents who left against medical advice (AMA). A resident who left AMA reported feeling unsafe and expressed dissatisfaction with the facility's care, yet there was no follow-up from the facility. The facility had 21 AMA discharges within a specified period, indicating a potential pattern of inadequate care or communication. Additionally, there were issues with documenting behavioral health concerns, as staff often did not record behaviors they did not witness, and there was a lack of enforcement of policies against substance use, which could exacerbate residents' conditions.
Inadequate Documentation and Communication in AMA Discharges
Penalty
Summary
The facility failed to properly document and communicate the circumstances surrounding the discharge against medical advice (AMA) for two residents, identified as #4 and #12. For resident #4, there was no nursing documentation completed, and the resident's wishes, preferences, or requests were not included in the documentation. Additionally, Adult Protective Services (APS) was not contacted. The resident expressed confusion and dissatisfaction with the facility, stating that they were not informed of their rights or offered transportation upon discharge. The resident's electronic health record (EHR) contained conflicting information about their orientation and anticipated stay at the facility. Resident #12's situation involved a lack of advance notification to the resident's caregiver about the discharge, and similar to resident #4, there was no nursing documentation or inclusion of the resident's wishes in the records. The resident required multiple cares, including wound care and antibiotics, and was initially told they would be discharged on a specific date. However, the discharge was postponed without clear communication, leading to the resident's frustration and desire to leave AMA. Interviews with staff members revealed inconsistencies in the facility's handling of AMA discharges, with some staff members acknowledging a lack of documentation and communication. Staff member F admitted to not contacting the ombudsman regarding resident #4's AMA discharge. The facility's policy on AMA discharges emphasized the importance of informing residents and their representatives of the risks and benefits, documenting discussions, and notifying appropriate entities if self-neglect is suspected, but these procedures were not followed in the cases of residents #4 and #12.
Failure to Complete Timely MDS Assessments
Penalty
Summary
The facility failed to complete required MDS assessments for several residents, leading to overdue assessments. Specifically, Quarterly MDS Assessments were not completed for four residents, with delays ranging from 44 to 61 days. An Annual MDS Assessment for one resident was 10 days overdue, and a Discharge MDS for another resident was 48 days overdue. The MDS coordinators, who were new to their roles, admitted to being behind on completing MDS assessments and were unsure of the specific timelines required for completion. Interviews with staff revealed a lack of oversight and consistent nursing administration, contributing to the delays. The MDS coordinators were inexperienced, having only recently started their roles, and had not previously completed MDS assessments. Despite some educational efforts by other staff members, the facility's policy on MDS completion was not adhered to, resulting in the overdue assessments. The responsibility for ensuring timely and accurate completion of MDS assessments ultimately fell to a staff member who acknowledged the oversight failure.
Failure to Timely Submit MDS Information
Penalty
Summary
The facility failed to submit Minimum Data Set (MDS) information within 14 days of completion for five of the fifteen sampled residents. Staff interviews revealed that the MDS assessments were late due to the inexperience of the two new MDS coordinators and a lack of consistent oversight in the building. Specifically, the Quarterly MDS for residents with Assessment Reference Dates (ARD) ranging from early September to late October were overdue by 44 to 61 days. Additionally, an Annual MDS and a Discharge MDS were also overdue by 10 and 48 days, respectively. The facility's policy requires all assessments to be transmitted to the designated CMS system within 14 days of completion, which was not adhered to in these cases.
Failure to Address High AMA Discharges
Penalty
Summary
The facility's quality assurance and performance improvement committee failed to identify and address concerns regarding a high number of residents discharging against medical advice (AMA) over the past year. Specifically, 21 residents left the facility AMA without physician discharge approval or a completed plan of care, putting them at risk for negative outcomes. One resident, who left the facility after less than 24 hours, reported feeling unsafe, encountering rude staff, and experiencing poor food quality. This resident expressed concerns about the facility's duty of care and noted that no follow-up occurred after their AMA discharge. The facility's records confirmed the 21 AMA discharges from January 2024 to the current date.
Non-Compliance with Smoking Policy and Resident Safety
Penalty
Summary
The facility failed to ensure compliance with its smoking policy, resulting in several deficiencies. One resident was observed smoking only a few feet away from the activities room door, allowing cigarette smoke to enter the facility, contrary to the policy requiring smoking to occur at least 25 feet from exits and common spaces. Additionally, a resident was found with personal tobacco in their room, indicating that smoking materials were not stored in the designated secure location as required by the facility's policy. Furthermore, the facility did not adequately assess the cognitive abilities of residents to determine their need for supervision while smoking. Two residents with low Brief Interview for Mental Status (BIMS) scores, indicating severe cognitive impairment, were listed as not needing supervision while smoking. This oversight suggests a failure to properly evaluate and document the residents' ability to safely smoke independently, as outlined in the facility's smoking policy.
Failure to Inform Residents of Psychotropic Medication Risks and Benefits
Penalty
Summary
The facility failed to ensure that residents or their representatives were fully informed and understood the risks and benefits of psychotropic medications. Specifically, two residents, identified as #6 and #9, were not provided with adequate information regarding their medications. Resident #6 expressed that he was unaware of the names, side effects, or benefits of the medications he was taking for his mood, and stated that no one had provided him with this information. Similarly, resident #9, who manages her own medical and financial decisions, reported taking medications for anxiety and depression without being informed of their side effects. Both residents' psychotropic consent forms lacked signatures from the residents or their representatives, indicating that the risks and benefits were not reviewed or understood. Staff member F, who completed the psychotropic consent forms, was unable to confirm whether the risks and benefits were discussed with the residents or their representatives. Furthermore, staff member F admitted to not having a clinical background and could not articulate the risks or benefits of psychotropic medication use. The facility's policy on the use of psychotropic medications, revised in June 2024, mandates that residents and/or their representatives be educated on the risks and benefits of such drug use, as well as alternative treatments. However, this policy was not adhered to in the cases of residents #6 and #9.
Inaccurate MDS Assessments for Diagnoses and Medications
Penalty
Summary
The facility failed to ensure accurate coding of MDS assessments for two residents regarding their diagnoses and psychotropic medication use. For one resident, a physician's progress note indicated diagnoses of anxiety and depression, but the Quarterly MDS did not reflect these diagnoses in the relevant sections. Additionally, the MDS failed to document the administration of antipsychotic medication, despite records showing the use of high-risk drug classes, including antipsychotics, antianxiety, and antidepressants during the look-back period. For another resident, the MDS did not mark any psychiatric or mood diagnoses, even though the resident was taking antipsychotic and antidepressant medications. The MDS inaccurately indicated that no antipsychotic medication was given. Interviews with staff members revealed a lack of awareness regarding these inaccuracies. The facility's policy on MDS completion requires staff to attest to the accuracy of the sections they complete, which was not adhered to in these cases.
Inadequate Discharge Planning and Communication
Penalty
Summary
The facility failed to provide an appropriate discharge plan for a resident, resulting in insufficient and incomplete documentation throughout the discharge planning process. Interviews with staff and review of the resident's electronic health record (EHR) revealed that the resident's caregiver was not notified of the discharge in advance, and there was no nursing documentation of the discharge. Additionally, the documentation lacked any statements, wishes, requests, preferences, or treatment goals for the resident. Staff member C expressed concerns about the discharge plan not being executed as communicated by social services, and NF5, another staff member, indicated confusion and lack of communication regarding the resident's discharge appropriateness due to medical acuity. The resident, who required daily wound care, antibiotics, and the removal of a central line catheter, was initially informed by staff member F about the discharge plan on November 5th, with an agreed discharge date of November 20th. However, on November 19th, the resident was informed that the discharge could no longer proceed as planned, leading to the resident's frustration and consideration of leaving against medical advice (AMA). Staff member A acknowledged that the discharge process required significant improvement, highlighting the facility's failure to adequately plan and communicate the discharge process to the resident and involved parties.
Failure to Provide Behavioral Health Services
Penalty
Summary
The facility failed to identify and document DSM diagnoses on the Resident Matrix and did not consistently document behaviors or offer behavioral health services to residents with a DSM diagnosis. Specifically, for one resident with anxiety disorder and major depressive disorder, the facility did not provide necessary behavioral health services. The resident's electronic health record (EHR) showed the last psychological evaluation was conducted over three years ago, and no behavioral health services were offered during the resident's stay, despite the resident experiencing anxiety and agitation. Interviews with staff revealed a lack of documentation and follow-up on behavioral health issues. Staff member C admitted to not documenting behaviors unless they were directly observed and expressed frustration that concerns about residents' behaviors, such as substance use, were not addressed by the facility's leadership. Staff member E indicated that while they could assess patients, they deferred to another staff member for psychotropic medication recommendations, despite the latter not having a clinical background. The facility's policy on behavioral health services stated that all residents should receive necessary services to maintain their highest level of mental and psychosocial functioning. However, the facility did not track behavioral health appointments, and staff training on behavioral health was deemed insufficient. The facility's assessment document indicated a need for behavior management and collaboration with mental health professionals, but these services were not adequately provided or documented for the resident in question.
Inadequate Wound Care and Documentation
Penalty
Summary
The facility failed to provide adequate wound care for a resident who required a wound vac for a pressure ulcer. The resident reported that the wound vac care was incorrect, and the device was only functional for a week. Staff instructed the resident to sit on the wound vac to seal the suction when it alarmed, which was not an appropriate intervention. The resident's condition worsened, leading her to leave the facility against medical advice. Interviews and record reviews revealed that staff member F, who was trained on wound care, was responsible for the resident's wound vac management. However, there was a lack of documentation regarding the difficulties with the wound vac, such as maintaining a seal, drainage amounts, and reasons for removing the wound vac. Staff member F admitted to not documenting these issues and believed the canister was changed only when full. Additionally, staff member B noted that the wound nurse was on maternity leave, and staff member F was having trouble with documentation and would change orders without proper documentation. The resident's medical records showed multiple physician orders for wound vac management, but there was no documentation of the resident's noncompliance or frequent dressing changes. The facility's policy required wound assessments and documentation of treatments, but these were not consistently followed. The resident's wound was noted to be deteriorating, with increased depth and surface area, and the facility failed to document the necessary interventions and modifications to the treatment plan.
Incomplete Investigations of Abuse and Neglect Allegations
Penalty
Summary
The facility failed to provide evidence of thorough investigations for allegations of abuse involving five residents. In one instance, a CNA allegedly forced a resident to drink water, but the investigation lacked details such as the identity of the alleged abuser, the person making the allegations, and any protective interventions during the investigation. The documentation was incomplete, missing interviews with staff or residents, and did not specify who conducted the investigation. In another case, a resident complained of verbal assault by a nurse who played loud music while dispensing medication. The investigation confirmed the nurse's behavior, but the documentation did not include the full name of the accused nurse, interviews with the accused, or protective measures for the resident. The investigation was incomplete, lacking details on who conducted it and whether the abuse allegation was substantiated. Additionally, a resident alleged neglect of care when a CNA failed to provide necessary services, resulting in a leaked foley bag. The investigation confirmed the neglect, but documentation was missing key details such as the identity of the alleged abuser, interviews, and care plan interventions. An altercation between two residents also lacked a thorough investigation, with missing interviews and protective measures. The facility's policy on abuse, neglect, and exploitation was not followed, and documentation was incomplete due to the absence of the social services director responsible for investigations.
Failure to Timely Report Allegations of Abuse
Penalty
Summary
The facility failed to report allegations of abuse within the required 24-hour timeframe for two residents. In the first incident, a resident complained of being verbally assaulted by a nurse who was playing music on a personal device while dispensing medication. This incident, witnessed by other staff members, occurred on June 8, 2024, but was not reported to the State Survey Agency until June 10, 2024. In the second incident, a resident was involved in a verbal altercation with a staff member, leading to police involvement. This incident occurred on September 1, 2024, but was not reported until September 4, 2024. During an interview, a staff member indicated that she was not informed of the second incident until she returned from vacation on September 4, 2024. The facility's policy requires immediate notification to appropriate agencies, no later than 24 hours after discovery of the incident, or within 2 hours in cases of serious bodily injury.
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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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