Yellowstone River Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Billings, Montana.
- Location
- 2115 Central Ave, Billings, Montana 59102
- CMS Provider Number
- 275029
- Inspections on file
- 27
- Latest survey
- December 31, 2025
- Citations (last 12 mo.)
- 31
Citation history
Health deficiencies cited at Yellowstone River Nursing And Rehabilitation during CMS and state inspections, most recent first.
A resident dependent on staff for toileting and hygiene activated her call light for over four hours without receiving needed assistance to change her brief. Multiple staff entered the room but did not provide care or turn off the call light, and communication breakdown at shift change contributed to the delay. The resident's family, unable to reach the facility, contacted local police for a welfare check.
A facility licensed for 160 beds did not employ a full-time social worker who met regulatory requirements, as the staff member in the social services director role held a psychology degree instead of a social work degree and lacked the required supervised healthcare experience. Despite the facility's census being below 120, regulations require a qualified social worker based on licensed bed count, not census. This deficiency was linked to concerns about meeting residents' mood, behavioral, and psychosocial needs.
Two residents did not have comprehensive, person-centered care plans with measurable objectives and timeframes. One resident with an indwelling catheter lacked specific care plan details for enhanced barrier precautions despite infection risk, while another resident with emotional and behavioral needs did not have individualized psychosocial interventions documented. Staff interviews and record reviews confirmed that care plans were not consistently updated to reflect residents' changing clinical and psychosocial needs.
A resident admitted for rehab services did not receive a complete provider assessment after refusing to continue with the initial provider due to concerns about bedside manner. The provider's visit was cut short, and no subsequent provider completed the required assessment or history and physical, leaving the resident's care needs unaddressed during her stay.
A resident with a history of alcohol abuse and ongoing emotional distress repeatedly requested mental health counseling and expressed concerns about staff treatment. Despite documented behavioral health needs and facility policy requiring assessment and referral, no counseling or mental health services were arranged, and no referrals were documented during the resident's stay.
A resident with a history of mental health concerns, including depression, anxiety, paranoia, and care refusals, did not receive individualized social services or behavioral interventions. The facility's assessments and care plan lacked accurate documentation and specific strategies for staff to address the resident's symptoms, and no evidence was found of referrals for needed mental health services.
A resident did not receive appropriate care for existing pressure ulcers, and the facility failed to implement effective measures to prevent new ulcers from developing. Surveyors found that necessary interventions and monitoring were not consistently provided.
A resident with severe protein calorie malnutrition and recent stroke experienced significant weight loss over one month. The resident was observed not receiving required assistance with eating, resulting in missed meals and visible difficulty during mealtimes. Documentation of required weekly weights was incomplete, and recommended dietary interventions were not implemented or monitored in a timely manner.
A grievance box was placed on a counter and blocked by a trash can, making it inaccessible to residents using wheelchairs. Staff sometimes had to assist residents in submitting grievances, and a resident reported being unable to submit grievances anonymously due to the box's placement and design.
Multiple residents reported and were observed receiving meal trays late and at improper temperatures, with some expressing significant hunger while waiting. Staff interviews confirmed ongoing issues with timely meal delivery to resident rooms, attributed to kitchen delays, unclear meal schedules, and inconsistent staff performance.
Staff cleaned a resident's room and disposed of personal items without the resident's presence or clear consent, despite the resident's history of homelessness and hoarding. The care plan did not specify how to involve the resident in decisions about his belongings, and there was no documentation of his agreement to the process. The resident was frustrated by the loss of his items, and the facility lacked a policy addressing room cleaning or hoarding.
Two residents with edema did not receive prescribed compression wraps or leg elevation as ordered by their physicians. Despite visible swelling and clear care plan directives, staff failed to apply the required interventions and inaccurately documented that treatments were provided. Staff interviews confirmed inconsistent application of the prescribed care.
Two residents did not receive respiratory care as ordered, including one who was observed multiple times without prescribed oxygen or with an empty tank and no oxygen warning sign posted, and another whose CPAP machine was unused, obsolete, and not maintained, despite staff documentation indicating regular use.
A resident with a traumatic brain injury and a history of elopement risk left the facility unsupervised through unsecured doors that lacked a wander guard alarm system. The resident was found by law enforcement after being unattended for about 45 minutes. Staff interviews and record reviews revealed that required checks of wander guard devices and door alarms were not consistently performed, and some staff were unclear about their responsibilities regarding elopement prevention.
Staff lacked the necessary education and clear procedures to monitor and verify the functionality of the wander guard alarm system for residents at risk of wandering or elopement. Multiple staff members were unsure of their responsibilities, and required checks of devices and exit doors were not consistently performed or documented, despite care plans and facility policy mandating these actions.
A resident exited the facility through a set of doors not equipped with a wander guard alarm system, allowing them to leave the property and access a public road without staff supervision. The facility's investigation did not address the lack of alarms on the initial exit doors, focusing only on the alarmed emergency egress doors, and failed to identify this as the root cause of the elopement.
A resident experienced an unwitnessed fall after sliding out of a chair in the dining room. Although the IDT identified a new intervention to have the resident sit on a couch instead of a chair, this intervention was not added to the care plan, leaving direct care staff without access to the updated fall prevention strategy.
The facility did not ensure that meals were served at appetizing and safe temperatures, as evidenced by multiple residents and staff reporting that food delivered to rooms was often cold and that yogurt was sometimes served warm. Resident council minutes over several months also documented ongoing concerns about cold food.
A resident was temporarily placed on a mattress on the floor in a storage area of the secure memory care unit due to a lack of available rooms. The area lacked a bathroom, sink, and call light, and staff monitored the resident and assisted with toileting in another part of the unit. The placement followed an unsuccessful attempt to move the resident to a regular unit, where wandering behaviors made it unsafe.
Two residents experienced room changes without receiving advance written notice or an explanation for the moves, as required by facility policy. Documentation was missing in both the EHR and progress notes, and representatives were not informed of the changes, only discovering them after the fact.
A resident's representative was not notified when the resident experienced increased confusion and agitation, resulting in a transfer to an acute care hospital for psychiatric evaluation. Although the representative was informed about an earlier incident of agitation, there was no documentation or communication regarding the hospital transfer, and the representative only became aware of the situation through another family member.
A resident was temporarily housed in a storage area within the secure memory care unit that lacked a sink and toilet, due to all regular rooms being occupied. Staff monitored the resident and assisted with toileting by escorting the individual to a shower room elsewhere in the unit. The area was confirmed to have no bathroom facilities during this time.
A resident was placed to sleep on a mattress on the floor in a storage room within the secure memory care unit that lacked a functioning call light system. Staff confirmed the resident spent at least one night in this room due to all regular rooms being occupied, and direct observation verified the absence of a call light.
A facility failed to limit PRN anti-anxiety medication to 14 days for a resident and did not provide adequate indication for antipsychotic use for another. One resident received Diazepam PRN for over eight months without documented anxiety, and the physician did not justify the lack of dose reduction. Another resident involved in altercations was prescribed Sertraline and later Seroquel without documented behaviors, and side effects were not consistently monitored. Staff interviews revealed documentation inconsistencies and a lack of questioning physician orders.
The facility failed to employ a Certified Dietary Manager, leading to increased risks for residents receiving nutritional services. Observations revealed issues with hygiene supplies, kitchen cleanliness, and pest control. The dietary manager, in the position for three months, is still completing certification and has not collaborated directly with the contract dietician, who visits bi-weekly and primarily works with the IDT.
The facility failed to maintain sanitary conditions in the kitchen, with issues such as lack of handwashing supplies, grease buildup, and mouse droppings. Food items were not labeled or dated, and staff did not wear beard coverings. Cleaning logs showed infrequent cleaning, and facility policies on food storage were not followed.
The facility failed to address kitchen cleanliness and pest control issues effectively. Observations revealed grease buildup, nonfunctional equipment, and mouse droppings in storage areas. Staff interviews indicated a lack of awareness about pest control frequency, and the QAPI program did not identify current concerns despite previous identification of issues.
The facility failed to maintain an effective pest control program, with observations of ants, beetles, and mouse droppings in various areas, including a resident's room and the kitchen. Staff interviews confirmed awareness of the pest issues, but pest control services had not been completed since March 2024, despite the facility's policy for ongoing pest control.
The facility failed to invite residents to participate in their care plan meetings, affecting four residents. One resident reported never attending a meeting despite staff mentioning them, while another had not been invited since the previous year. A third resident had not attended a meeting in several months, and a fourth was unaware of care plans altogether. Staff acknowledged being behind on scheduling these meetings.
The facility failed to maintain a clean and sanitary environment, as evidenced by reports of bugs and dirty conditions in several residents' rooms and common areas. Despite residents' complaints and staff observations, there was a lack of effective action to address the issues. Housekeeping staff were assigned daily cleaning tasks, but persistent problems indicated non-compliance with the facility's cleaning policy.
The facility failed to properly dispose of discontinued medications for two discharged residents. Insulin pens labeled for these residents were found in the medication cart, along with several other pens with illegible or missing labels. A staff member was unaware of the correct procedure for handling these medications, contrary to the facility's policy requiring their destruction or return to the pharmacy.
The facility's medication error rate was 11.54%, exceeding the acceptable threshold. An LPN administered incorrect dosages and types of medications to two residents, including vitamin D3 and a multivitamin with minerals, and a cranberry tablet without a specified dosage. The errors were acknowledged by the LPN during a follow-up interview.
A resident experienced wrist pain due to inadequate wheelchair armrest support, leading to frequent repositioning attempts. The facility identified the issue but delayed follow-up with the wheelchair provider, resulting in a deficiency in maintaining the resident's highest practicable level of functioning.
Two residents reported rough handling and degrading language by a staff member, leading to an investigation that substantiated the abuse allegations. The staff member was suspended and did not return to work.
A facility failed to recognize a concave mattress as a potential restraint for a resident and did not conduct a risk assessment, obtain consent, or monitor its use. Staff interviews indicated the mattress was used to prevent falls due to the resident's history of falls and injuries. However, the resident's medical record lacked documentation of these necessary procedures.
A diabetic resident reported long, curling toenails, indicating a lack of effective foot care. Staff interviews revealed confusion about scheduling podiatry appointments, with one staff member uncomfortable cutting the resident's nails due to health conditions. The resident's care plan lacked documentation of podiatry needs, and no appointments were recorded in the electronic health record.
A facility failed to address a trip hazard by using a large mattress as a fall mat, obstructing a resident's access to the restroom and causing a staff member to trip. Additionally, a resident was exposed to hazardous materials by being allowed to keep bug spray in their room, despite potential health risks outlined in the Safety Data Sheet.
The facility failed to employ a competent Dietary Manager, leading to numerous deficiencies in the kitchen, including unsanitary conditions and nonfunctional equipment. Observations revealed issues such as grease buildup, mouse droppings, and unlabeled food items. The dietitian did not regularly consult with the dietary manager, who was still completing certification. A grievance about bugs in the food was filed, and staff acknowledged ongoing issues with mice.
A facility failed to follow enhanced barrier precautions during wound care and medication administration for a resident, as a staff member did not wear a gown during these procedures. Additionally, a worn recliner in a resident's room was not repaired, creating an uncleanable surface. Despite ongoing training on infection control, there was a misunderstanding among staff about when gowns should be worn, and no maintenance requests were made for the damaged recliner.
The facility failed to maintain essential kitchen equipment, including the oven, refrigerators, and ice machine, which were non-functional for an extended period. Observations revealed no paper towels near sinks, a warm dessert refrigerator, and a plugged sink drain. Staff reported issues through the TELS system, but maintenance logs lacked documentation of repairs.
Failure to Respond Timely to Resident Call Light for Dependent Personal Care
Penalty
Summary
Staff failed to respond in a timely manner to a resident who required assistance with activities of daily living, specifically with changing briefs due to urinary and bowel incontinence. The resident activated her call light, which remained on for over four hours, and multiple staff members entered her room but did not provide the needed personal care or turn off the call light. The resident ultimately contacted a family member for help, who, after being unable to reach the facility, called the local police to conduct a welfare check. Interviews with staff revealed that shift change communication was lacking, as incoming staff were not informed of the resident's need for assistance. Staff prioritized other residents based on perceived urgency and did not follow through with the resident's request, despite being aware of her call light. Documentation showed that staff were instructed to leave call lights on until all resident needs were met, but this led to confusion and further delay in care. The resident was dependent on staff for toileting and hygiene, as indicated by her care plan and assessment, and had a history of urinary and bowel incontinence. Despite being checked on earlier in the day, her needs were not met during the evening shift, resulting in an extended period without necessary personal care. Facility records confirmed the prolonged call light response time and the lack of timely assistance provided to the resident.
Failure to Employ Qualified Full-Time Social Worker in Facility Licensed for Over 120 Beds
Penalty
Summary
The facility failed to hire and employ a full-time social worker who met the regulatory requirements for a facility licensed for more than 120 beds. Specifically, the facility was licensed for 160 beds, but the individual in the social services director position held a bachelor's degree in psychology rather than in social work, and did not have the required one year of supervised experience in a healthcare setting. Another staff member working in a social services role also did not have a degree. The facility's job description for the social worker position required a bachelor's degree in social work and a state social work license, but the current staff member did not meet these qualifications. Interviews with facility staff revealed that the facility's census had never reached 120 residents, and staff believed that having two staff members in social services roles was sufficient to meet regulatory requirements. However, regulatory review confirmed that the requirement for a qualified full-time social worker applies to facilities with more than 120 beds, regardless of current census. The report also referenced related concerns with residents not receiving necessary care and services for mood, behavior, and psychosocial needs, as outlined in F656 and F740.
Failure to Develop Person-Centered Care Plans with Measurable Objectives
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes for two of eight sampled residents. For one resident with an indwelling urinary catheter and a history of spinal cord dysfunction and obstructive uropathy, the care plan did not include specific information regarding enhanced barrier precautions, despite the resident's frequent catheter changes and risk for urinary tract infections (UTIs). The care plan only referenced general infection control precautions and did not address the need for enhanced measures, even though the resident had experienced a UTI and was placed on antibiotics. For another resident with a history of alcohol abuse (in remission) and significant emotional and behavioral needs, the care plan lacked a comprehensive, person-centered focus on emotional and behavioral interventions. Although the resident exhibited emotional instability, anxiety, and concerns about staff interactions, the care plan primarily included monitoring and medication interventions without detailing specific strategies to address the resident's psychosocial needs during episodes of distress. The psychosocial assessment and social service notes documented the resident's emotional challenges and requests for mental health support, but these were not reflected in the care plan interventions. Interviews with facility staff revealed that while the interdisciplinary team was involved in care planning, there were gaps in updating care plans to reflect changes in residents' clinical or psychosocial status. Staff acknowledged that information about enhanced barrier precautions and psychosocial interventions should have been included in the care plans but were not consistently added following assessments or team discussions. The facility's policy required comprehensive, person-centered care plans with measurable objectives and timeframes, but this was not followed for the two residents in question.
Failure to Complete Required Provider Assessment After Resident Refusal
Penalty
Summary
A provider failed to complete a comprehensive assessment and review of a resident's total program of care during a required visit. The resident, who was admitted for rehabilitation services following a hospital stay for multiple medical conditions, expressed dissatisfaction with the initial provider's bedside manner and felt her concerns were not adequately addressed. During the provider's first visit, the resident became upset and asked the provider to leave before a physical exam or full assessment could be completed. The provider documented that the assessment was incomplete and noted the resident's refusal to continue the visit. Following this incident, the resident did not receive a subsequent visit from another provider to complete the required assessment, history and physical, or to make recommendations for ongoing care. Staff attempted to arrange for the resident to be seen by other providers, but the resident either refused or the attempts were unsuccessful. As a result, the resident's comprehensive care needs were not fully evaluated or addressed during her stay, contrary to facility policy and regulatory requirements.
Failure to Provide Behavioral Health Services Following Resident Request
Penalty
Summary
A deficiency occurred when the facility failed to provide necessary behavioral health care and services to a resident who requested mental health counseling. The resident, admitted with a history of alcohol abuse (in remission), exhibited consistent emotional behaviors and expressed concerns about her care and treatment by staff from the time of admission. She reported feeling mistreated, submitted a grievance regarding staff interactions, and specifically requested a different provider after expressing dissatisfaction with her assigned provider. Despite these documented concerns and requests, the resident did not receive access to mental health counseling or services during her stay. Interviews with facility staff revealed that the resident's emotional and behavioral issues were recognized by staff, including daily fluctuations in mood and difficulty settling into the facility. Staff acknowledged the resident's request for mental health services and noted her history of mental health concerns. However, there was no documentation of any referrals made for counseling, therapy, or mental health services, even though the facility's policy required monitoring, documentation, and appropriate follow-up for behavioral health needs. The social services staff member responsible for coordinating such services confirmed that no referrals were made, and the facility was unable to provide documentation of any behavioral health service referrals for the resident. The resident's medical record and care assessments consistently documented her emotional distress, paranoia about medications, and ongoing conflicts with staff. Multiple progress notes described her as excitable, emotional, and having difficulty regulating her emotions. The facility's own behavioral health policy outlined the need for timely assessment and referral for behavioral health services, but these steps were not completed for the resident, despite clear indications and requests for such support.
Failure to Provide Individualized Social Services and Behavioral Interventions
Penalty
Summary
The facility failed to provide individualized, medically-related social services and did not accurately or thoroughly assess a resident's mood, behavior, and psychosocial status. The resident in question exhibited mood symptoms, took an antidepressant, displayed anxiety, paranoia, frequently refused care, and acted out toward others. Despite these ongoing concerns, the facility did not ensure her care plan included specific, individualized interventions for staff to use when the resident displayed symptoms or concerns related to mood, behavior, or psychosocial issues. There was also no documentation of referrals for mental health services, even though such a need was identified by staff. Record reviews and staff interviews revealed inconsistencies and omissions in the resident's assessments and care planning. The psychosocial assessment contained errors, such as an impossible BIMS score, and failed to document interventions for care refusals or behavioral symptoms. Progress notes lacked consistent and individualized interventions, with some entries appearing to be repeated from previous notes. The care plan addressed issues like depression and paranoia but only included generic interventions such as monitoring medications or providing a lock box, without specific strategies for staff to address the resident's behaviors. No documentation was provided to show that mental health referrals were made prior to the end of the survey.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through surveyor observations and documentation review, which indicated that residents either did not receive necessary interventions for existing pressure ulcers or were not monitored and assessed adequately to prevent new pressure ulcers from forming.
Failure to Provide Adequate Assistance and Monitoring for Resident with Severe Weight Loss
Penalty
Summary
A resident with a recent history of stroke and a new diagnosis of Severe Protein Calorie Malnutrition experienced a significant weight loss of 7.65% in one month. Observations revealed that the resident was left asleep with an untouched breakfast tray, which was later discarded without any attempt to assist or encourage intake. During lunch, the resident was seen struggling to eat independently, with food falling off the fork and visible frustration, yet no staff assistance was provided. The care plan indicated the resident required extensive assistance with eating, but this intervention was not implemented during observed meals. Record review showed the resident was to be weighed weekly, but a required weight was missing from documentation. Despite the physician's note identifying significant weight loss and recommending a Registered Dietitian consult and nutritional supplements, there was no evidence of dietary follow-up or intervention in the progress notes. Staff interviews confirmed the resident had not been included in weight loss monitoring until after the deficiency was identified, and dietary interventions were not updated in a timely manner.
Grievance Box Inaccessible to Wheelchair Users
Penalty
Summary
The facility failed to provide a wheelchair-accessible grievance box, preventing residents who use wheelchairs from independently or anonymously submitting grievances. During observation, the grievance box was found placed on top of a counter in the main lobby, with a trash can on the floor in front of it, creating a physical barrier. The box required the lid to be pulled down to deposit a form, further complicating access for those with limited mobility. Staff confirmed that they sometimes had to assist residents in wheelchairs to submit grievances, and a resident who relies solely on a wheelchair reported being unable to reach the box and therefore had to hand grievances directly to staff, compromising anonymity. The resident also expressed a desire for the box to be more accessible and discreet.
Delayed and Improper Meal Service to Resident Rooms
Penalty
Summary
The facility failed to serve resident meal trays to rooms in a timely manner and according to posted mealtimes, resulting in multiple residents experiencing late and lukewarm meals. Observations and interviews revealed that residents who consistently ate in their rooms reported their food was often served thirty minutes late and was usually lukewarm. On several occasions, residents expressed significant hunger while waiting for their meals, with one resident rating their hunger as ten out of ten. Meals were observed being delivered after the designated end time for meal deliveries, and residents commented on the food being served late and not at the proper temperature. One resident expressed concern about the late meal affecting their ability to attend a scheduled appointment. Staff interviews confirmed that meal trays were often late getting to resident rooms, with some staff acknowledging that the facility could improve the timeliness of tray delivery. Staff attributed delays to food not coming out of the kitchen quickly enough and to the order in which halls were served. There were also reports of CNAs delaying food service due to inattentiveness. Meal delivery times were not clearly posted or communicated to residents, leading to confusion and unmet expectations regarding when meals would be served.
Failure to Respect Resident's Personal Belongings During Room Cleaning
Penalty
Summary
Facility staff failed to respect a resident's personal belongings during a room cleaning, disposing of items without the resident's presence or awareness. The resident, who had a documented history of homelessness and hoarding, kept various personal items in his room, including painted rocks, a handmade plant, and papers, none of which posed a safety hazard at the time of observation. Staff cleaned the room while the resident was absent, removed items from display, and discarded stored food, citing routine housekeeping and the need to prevent hoarding. The resident expressed frustration and distress upon discovering his items were missing or displaced, indicating he was not informed or consulted about the cleaning or the disposal of his belongings. Review of the resident's care plan showed interventions related to his history of hoarding and the need to maintain a safe environment, but did not specify how staff should ensure the resident was comfortable with the cleaning process or aware of what was being discarded. Staff interviews revealed that while the resident had previously consented to staff cleaning his room, there was no documentation or clear communication regarding which items could be removed or discarded. Additionally, the facility lacked a specific policy on hoarding or room cleaning for safety concerns, and there was no evidence of a documented agreement or contract outlining the resident's preferences or consent for the disposal of his personal items.
Failure to Follow Physician Orders for Edema Management
Penalty
Summary
The facility failed to follow physician orders for edema treatment for two residents with mobility issues. Observations revealed that both residents consistently exhibited swelling in their lower legs and feet, yet were not wearing the prescribed elastic bandages or compression stockings. Additionally, interventions such as leg elevation were not implemented as directed in their care plans. Despite these omissions, staff documented in the Treatment Administration Records that the interventions had been performed on the relevant dates. Interviews with staff confirmed that the prescribed treatments were not consistently applied, and some staff indicated that only certain nurses would perform these tasks. Review of the residents' care plans and treatment records showed clear orders for the use of compression wraps and leg elevation to manage edema. However, these interventions were not observed during multiple surveyor visits, and staff documentation did not accurately reflect the care provided. Weekly skin check assessments also failed to note the presence of edema, despite visible swelling. The lack of adherence to physician orders and inaccurate documentation contributed to the identified deficiency.
Failure to Follow Physician Orders for Oxygen and CPAP Administration
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents by not following physician orders for oxygen and CPAP administration. One resident, who had an order for continuous oxygen at 2 L per minute via nasal cannula, was repeatedly observed without oxygen or with an empty oxygen tank attached to her wheelchair. The resident's room lacked the required oxygen warning sign, and multiple empty oxygen tanks were present. Documentation indicated that oxygen was administered only 92% of the time, despite the order for continuous use. Another resident, who had an order for nightly CPAP use for obstructive sleep apnea, had not used the CPAP machine for an extended period. The CPAP equipment was found buried, dusty, missing a power cable, and without a current biomedical inspection date. Despite this, staff documentation reflected that the CPAP was applied most nights, which was inconsistent with the resident's statements and the observed condition of the equipment. The order for CPAP was eventually removed, but the order to clean the facemask remained.
Resident Elopement Due to Unsecured Exit and Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident with a traumatic brain injury and a known history of agitation and elopement risk was able to leave the facility unsupervised through unsecured doors. The resident was last seen in his room and, after a door alarm was heard, staff discovered that the resident was missing. The facility's elopement protocol was activated, and the resident was found by law enforcement approximately 0.2 miles from the facility after being unattended for about 45 minutes. The doors used for the elopement were not equipped with a wander guard alarm system, and the area was not occupied by staff or residents at the time. Interviews and record reviews revealed that the exit doors on certain units, including the one used during the elopement, had not been secured with a wander guard alarm system for at least four years. Staff believed that the emergency exit door alarms were sufficient, but these alarms only sounded when the door was opened and did not provide the same level of alert as the wander guard system. Additionally, the resident's care plan had previously included 1:1 monitoring and a wander guard device, but the monitoring was discontinued following an IDT review, and there was uncertainty among staff about the evaluation process and documentation for this decision. Further review showed that multiple other residents were assessed as being at risk for elopement and were supposed to have wander guard devices in place, with staff required to check these devices every shift. However, interviews indicated that these checks were not consistently performed, and some staff were unclear about who was responsible for ensuring the devices and door systems were functioning. The facility's own elopement policy required regular checks of both door keypads and monitoring devices, as well as immediate staff response to alarms, but these procedures were not reliably followed.
Failure to Ensure Staff Competency and Monitoring of Wander Guard Alarm System
Penalty
Summary
The facility failed to ensure that nurses and nurse aides possessed the necessary education and competencies to monitor and verify the functionality of the wander guard alarm system for residents at risk of wandering and elopement. Multiple staff interviews revealed a lack of clarity regarding who was responsible for checking the wander guard devices and exit door alarms, as well as how often these checks should occur. Staff members were unaware that not all exit doors were equipped with the alarm system, and there was no consistent process in place for verifying device or door functionality. Documentation confirming daily or shift-based checks, as required by facility policy and resident care plans, was not available during the survey. Care plan reviews for six residents identified as being at risk for wandering or elopement indicated that their wander guard devices were to be checked every shift to ensure proper function. However, the facility was not using the manufacturer's device to verify the functionality of the wander guard system for either residents or doors. The facility's elopement policy required daily checks of door keypads and nightly checks of monitoring devices, but these procedures were not being followed or documented. This lack of adherence to policy and insufficient staff education led to a deficiency in ensuring the safety and well-being of residents with elopement risks.
Failure to Identify and Address Unalarmed Exit Doors Leading to Resident Elopement
Penalty
Summary
The facility failed to conduct a thorough investigation after a resident exited the building through doors that were not equipped with a wander guard alarm system. The resident was able to leave the property, access a public road, and travel 0.2 miles on foot without staff supervision. The facility's report indicated that while the emergency egress door at the end of the hall was alarmed and staff responded to the alarm, they did not see any residents outside and subsequently contacted local law enforcement. The resident was later found and returned to the facility by police. The investigation did not address the fact that the first set of exit doors, which the resident used to leave, were not equipped with a wander guard alarm system, allowing the resident to reach the emergency egress doors and exit the facility. Interviews revealed that the interdisciplinary team (IDT) reviewed the incident, but the lack of a progress note summary in the resident's medical record was noted. Staff confirmed that certain doors in the facility, including those on the sapphire and crossroads units, were not alarmed with a wander guard system and that this was not identified as the root cause of the elopement. The rationale provided was that the second set of doors, which were emergency egress doors, were alarmed and would alert staff if a resident exited. However, the absence of alarms on the first set of doors was not addressed as a contributing factor to the resident's ability to elope.
Failure to Update Care Plan with New Fall Intervention
Penalty
Summary
A deficiency occurred when the facility failed to update a resident's care plan with a new fall intervention identified by the Interdisciplinary Team (IDT) after the resident experienced an unwitnessed fall. The resident, who was sitting in a chair in the dining room, attempted to scoot forward and slid out of the chair, landing on her buttocks. The IDT reviewed the incident and suggested a new intervention: redirecting the resident to sit on a couch instead of a chair, as she was able to get up from the couch without difficulty. This intervention was documented in the IDT event review note but was not added to the resident's care plan. As a result, the direct care staff did not have access to the updated intervention, which was necessary to address the specific circumstances of the resident's fall. The facility's policy requires that care plans be revised as information about residents and their conditions change, and that the IDT must review and update care plans when there is a significant change in condition or when desired outcomes are not met. Despite these requirements, the new intervention was not incorporated into the care plan, leading to a deficiency in care planning and communication.
Failure to Serve Meals at Appropriate Temperatures
Penalty
Summary
The facility failed to ensure that meals were served at an appetizing and safe temperature, resulting in dissatisfaction among residents. Multiple residents reported receiving meals that were not hot, with specific complaints about both breakfast and lunch trays being cold when delivered to their rooms. One resident also noted that yogurt, which should be served cold, was often delivered warm. Staff confirmed that they regularly received complaints from residents about room trays being cold. Additionally, a review of resident council meeting minutes over several months consistently documented concerns about food being served cold, both in resident rooms and in the dining room. These findings indicate that the facility did not maintain appropriate food temperatures during meal service, as evidenced by direct resident interviews, staff statements, and ongoing documentation in resident council minutes.
Resident Placed in Non-Residential Area Without Basic Amenities
Penalty
Summary
A resident was placed in a non-residential area of the secure memory care unit, specifically the Country Store, due to a lack of available rooms. The resident was found lying on a mattress on the floor in a room that lacked basic amenities such as a sink, bathroom, or call light. The area was described as a storage room with the lights off and the door partially closed. Staff interviews confirmed that the resident had been temporarily placed in this area after an unsuccessful attempt to move him to a regular unit, where he was unable to stay due to wandering behaviors. Staff also reported that, prior to being placed in the Country Store, the resident had slept on a couch in the television room, which was too bright and noisy for rest. The decision to place the resident in the Country Store was made because all rooms in the secure memory care unit were occupied, and the resident could not safely remain outside the secure unit. Staff acknowledged the absence of a call light and bathroom in the Country Store and stated that they monitored the resident closely and assisted him to the toilet in another part of the unit as needed. The area used for the resident's temporary accommodation was observed to be two open spaces with no private closet, bathroom, or sink, and was adjacent to the hallway with access to a courtyard.
Failure to Provide Written Notice for Room Changes
Penalty
Summary
The facility failed to provide written notice, including the reason for room changes, to residents and their representatives prior to making room changes for two of three residents reviewed. For one resident, records showed multiple room changes over several weeks, but there was no documentation of Notification of Room/Roommate Change forms for two of the moves, nor were any of the room or unit changes documented in the resident's progress notes. The resident's representative confirmed that they were not notified, either verbally or in writing, about the subsequent moves and were unaware of the resident's current location. For another resident, documentation revealed a room change without a corresponding Notification of Room/Roommate Change form or any mention of the move or its reason in the progress notes. The resident's representative stated they were not informed of the room change and only discovered it upon visiting and being unable to locate the resident. The facility's policy requires advance written notice, including the reason for the change, to all parties involved prior to any room or roommate assignment changes.
Failure to Notify Representative of Resident Transfer After Change in Condition
Penalty
Summary
The facility failed to notify a resident's representative when there was a significant change in the resident's condition that required transfer to an acute care hospital for psychiatric evaluation. According to interview and record review, the resident's representative was informed about an attempted elopement and agitation but was not notified when the decision was made to transfer the resident to the hospital. The representative only learned of the transfer after another family member visited the facility and was told the resident was in the hospital. Review of the resident's hospital records indicated increased confusion, agitation, and medical interventions, but facility progress notes did not document any notification to the representative regarding the change in condition or the transfer.
Resident Placed in Room Without Bathroom Facilities
Penalty
Summary
A deficiency was identified when a resident was temporarily placed in a room known as the Country Store, located in the secure memory care unit, which did not have a sink or toilet. Staff interviews confirmed that all regular rooms in the secure unit were occupied, and the resident was placed in the Country Store as a temporary measure. The area was described as two open spaces used for storage, lacking both a sink and a bathroom. Staff reported that they monitored the resident closely and assisted with toileting by escorting the resident to a shower room at the other end of the unit. Observations confirmed the absence of bathroom facilities in the Country Store during the period the resident was housed there.
Resident Placed in Room Without Call Light
Penalty
Summary
A deficiency occurred when a resident was placed to sleep on a mattress on the floor in a room known as the Country Store, located in the secure memory care unit, which did not have a functioning call light system. Multiple staff interviews confirmed that the resident spent at least one night in this room without access to a call light, as all regular rooms in the unit were occupied. Staff were aware of the lack of a call light in the Country Store but reported having no other options for the resident's accommodation at that time. Facility management was informed of the situation, and staff were instructed to resolve the room issue the following morning. Direct observation confirmed the absence of a call light in the Country Store.
Failure to Limit PRN Anti-Anxiety Medication and Inadequate Indication for Antipsychotic Use
Penalty
Summary
The facility failed to ensure that PRN anti-anxiety medication was limited to 14 days for a resident and did not provide adequate indication for the use of an antipsychotic for another resident. Resident #49 was prescribed Diazepam 2 mg daily for anxiety, with an additional PRN dose of 1 mg as needed. This PRN order was renewed every 14 days for over eight months without documented signs of anxiety during the times the PRN dose was administered. The pharmacy recommended a gradual dose reduction, but the physician did not provide documentation to support why a reduction was contraindicated, nor did they document the resident's behaviors or response to the medication. Resident #99 was involved in physical altercations with other residents and was prescribed Sertraline for anxiety, which was later increased without documented signs of anxiety or depression. The facility failed to monitor and document the side effects of the medication as ordered by the physician. After another altercation, Seroquel was prescribed for sundowning with agitation, but the facility did not document the behaviors leading to this decision. Staff interviews revealed a lack of consistent documentation of behaviors and a lack of understanding that staff could question physician orders for psychotropic medications.
Deficiency in Dietary Management and Oversight
Penalty
Summary
The facility failed to employ a Certified Dietary Manager to oversee the food and nutrition services, which increased the risk of negative outcomes for all residents receiving nutritional services. During an initial observation of the kitchen, several concerns were identified, including issues with employee hygiene supplies, soiled kitchen equipment, improper food storage, cleanliness of the dietary department, and pest control. These observations were linked to deficiencies noted under F812, F908, and F925. Interviews with staff revealed that the facility relies on a contract dietician who visits every other week and is available for consultation. However, the dietician has not met with the dietary manager, who has been in the position for about three months and is still completing a Certified Food Manager program. The dietary manager's lack of certification and the absence of direct collaboration with the dietician were highlighted as contributing factors to the deficiency. The facility had to promote internally for the Dietary Manager position due to hiring challenges, and the dietician primarily works with the Interdisciplinary Team (IDT) rather than directly with the dietary manager.
Sanitation and Food Safety Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen and dietary storage areas, as observed during a survey. Key issues included the absence of paper towels and soap at handwashing stations, grease and dirt buildup on kitchen equipment, and the presence of mouse droppings in storage areas. Additionally, food items in the walk-in cooler and freezer were not labeled or dated, and there was a lack of appropriate pest control measures. These deficiencies were noted during multiple observations over several days, indicating a pattern of non-compliance with sanitary standards. Furthermore, kitchen staff were observed not wearing beard coverings while serving and preparing food, despite having facial hair. Interviews with staff revealed that beard coverings were not available, and there was a lack of adherence to food labeling and dating protocols. The facility's cleaning logs showed infrequent cleaning of the storeroom, and the facility's policy on food storage was not being followed, as evidenced by the uncovered, unlabeled, and undated food items in the refrigerator and freezer.
Kitchen Cleanliness and Pest Control Deficiencies
Penalty
Summary
The facility failed to effectively identify, correct, and monitor quality-deficient practices related to kitchen cleanliness and pest control, as observed during a survey. During an initial tour of the kitchen, several issues were noted, including grease and dust buildup on stove burner handles, grease accumulation under the grill, and a nonfunctional oven being used for storage. Additionally, the microwave was found with debris and dirt, and a puddle of water was present on the kitchen floor without a wet floor sign. Mouse droppings were observed in the food storage and chemical storage areas, and a bag of cake mix was found with a hole and mouse droppings inside. Items in the walk-in refrigerator were not labeled or dated, and several pieces of kitchen equipment were nonfunctional. Interviews with staff revealed a lack of awareness regarding the frequency of pest control visits and acknowledgment of ongoing issues with mice in the kitchen. Despite the facility's Quality Assurance and Performance Improvement (QAPI) program identifying kitchen issues since April, the current concerns were not detected through their monitoring or oversight. The facility's Quality Assurance and Performance Plan, reviewed in January 2024, emphasized prioritizing topics for Performance Improvement Projects (PIPs) based on current needs, yet the existing deficiencies in the kitchen were not adequately addressed.
Pest Control Deficiency in Facility
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by multiple observations of pests in various areas, including the kitchen, 200 and 300 halls, and a resident's room. An ant was observed near a resident's recliner, and dead insects were found scattered on the floor in the 300 hallway. Beetles were seen crawling in the hallway and near exit doors in the 200 unit. Staff interviews confirmed the presence of ants and other bugs, with one staff member acknowledging a bug problem, particularly with ants. Another staff member noted that bugs entered through screenless windows, but was unaware of any actions taken by the facility to address the issue. During a kitchen tour, mouse droppings were found in the dry food storage and chemical storage areas, with a significant amount along the floor perimeter. A plastic tote containing cake mix had a bag with a hole chewed through it, and mouse droppings were present at the bottom of the tote. Although mouse traps were placed in the kitchen, a staff member admitted awareness of the mice issue and mentioned that the pest control company visited monthly. However, facility records showed that pest control services had not been completed since March 2024, despite a policy stating the facility should maintain an ongoing pest control program.
Failure to Invite Residents to Care Plan Meetings
Penalty
Summary
The facility failed to invite residents to participate in their care plan meetings, affecting four out of 43 sampled residents. Resident #89 reported that although staff mentioned care meetings, they were never conducted, and there was no evidence in the electronic health record (EHR) of any invitations. Resident #63 expressed a desire to attend care plan meetings but had not been invited since December of the previous year. Similarly, resident #21 had not attended a care plan meeting in eight or nine months, despite wanting to participate. Resident #91 was unaware of what a care plan was and had never been invited to a meeting. A staff member confirmed that care plans are updated as needed, but acknowledged that the facility was behind on scheduling these meetings. The EHR for resident #91 showed no record of invitations or participation in care conferences since their admission. Staff interviews revealed that social services were responsible for coordinating and inviting residents to these meetings, but there was a backlog in care plan scheduling.
Deficiencies in Maintaining a Clean and Sanitary Environment
Penalty
Summary
The facility failed to maintain a clean and sanitary environment for several residents, as evidenced by multiple observations and interviews. Resident #89 reported bugs in her room, and staff provided bug spray instead of addressing the root cause. A large spider was observed in a common area, and staff noted small bugs on the floor. Resident #63's bathroom was observed to be dirty, with a brown build-up stain and a urine smell, and remained in the same condition over several days. Resident #32's room and shared bathroom were found with debris, a soiled brief, stained slippers, and beetles, despite residents reporting the issue to staff multiple times. Staff interviews revealed a lack of awareness or action taken to resolve the bug problem. The 300 hallway and resident rooms for residents #39 and #65 were also not consistently cleaned. Observations noted a urine smell, water damage, and debris on the floors. Bug remnants were found in the hallway, and dark fabric debris and sticky floors were noted in resident #65's room. Staff interviews indicated that housekeeping staff were assigned daily cleaning tasks, but there was a lack of communication and follow-up on the bug issues. The facility's cleaning policy required regular disinfection, but the observed conditions suggested non-compliance. Despite checklists indicating cleaning was completed, the persistent issues pointed to deficiencies in maintaining a sanitary environment.
Improper Disposal of Discontinued Medications
Penalty
Summary
The facility failed to ensure the proper disposal or destruction of discontinued medications for two residents who had been discharged. During an observation of the medication cart, an Insulin Aspart FlexPen labeled for a resident who was discharged six days prior was found. Additionally, three Insulin Lispro KwikPens labeled for another resident who was discharged over two weeks earlier were also discovered. Further inspection of the medication cart revealed several insulin and Victoza pens with partially removed, illegible, or no labels. A staff member interviewed was unaware of the procedure for handling unused insulin or Victoza pens and speculated that they belonged to discharged residents. The facility's policy indicated that discontinued medications should be destroyed or returned to the issuing pharmacy, but this was not adhered to in these instances.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent, resulting in an error rate of 11.54 percent for two of the 43 sampled residents. During a medication administration observation, staff member G administered incorrect dosages and types of medications to resident #37. Specifically, the resident received vitamin D3 at a dosage of 20 mcg instead of the ordered 25 mcg, and a multivitamin with minerals instead of the prescribed multivitamin without minerals. These discrepancies were identified upon reviewing the resident's Medication Administration Record (MAR) dated 7/17/24. In another instance, staff member G administered a cranberry tablet to resident #309 without a specified dosage, as the MAR only indicated a daily cranberry tablet order without dosage details. During a follow-up interview, staff member G acknowledged the errors in administering the vitamin D3, cranberry tablet, and multivitamin. The facility's policy on medication orders requires that orders include the name, strength, dosage, and frequency of administration, which was not adhered to in these cases.
Failure to Accommodate Resident's Wheelchair Needs
Penalty
Summary
The facility failed to accommodate the needs and preferences of a resident, leading to a deficiency in maintaining the resident's highest practicable level of functioning. The resident, who was observed attempting to reposition himself multiple times using his hands and forearms, was experiencing pain in his left wrist. This pain was documented in the nurse progress notes, and it was noted that the resident was favoring his wrist and not using it as much. A provider identified that the motorized wheelchair's armrest did not accommodate the length of the resident's left forearm, necessitating frequent position changes. An x-ray revealed a chronic ligament tear and early advanced collapse of the resident's left wrist. The Interdisciplinary Team (IDT) identified the root cause of the wrist pain as the resident pushing himself back in the wheelchair. The intervention was to have therapy evaluate the armrests and educate the resident on alternative repositioning methods. However, the occupational therapy notes indicated a delay in follow-up with the wheelchair provider for readjustment. Communication with the wheelchair provider was initiated, but there was no further written communication provided to confirm the evaluation of the wheelchair. This lack of timely action contributed to the deficiency in addressing the resident's needs.
Failure to Protect Residents from Abuse by Staff Member
Penalty
Summary
The facility failed to protect residents from abuse by a staff member, identified as NF4, involving two residents. Resident 304 reported that NF4 was rough during a transfer and used the term 'diaper' during incontinence care, which she found degrading. She also experienced right knee and leg pain following the incident and expressed a desire not to have NF4 care for her anymore. Resident 305 similarly reported that NF4 was rough during care and ignored his expressed needs, leading him to prefer not to receive care from NF4. The incident was reported to the State Survey Agency, and NF4 was immediately suspended pending investigation. The investigation confirmed the allegations of abuse. NF4 refused to provide a statement and did not return to work at the facility. Other residents on the unit were interviewed, and none reported issues with NF4. The incident was discussed in the facility's QAPI meeting.
Failure to Identify and Document Concave Mattress as a Restraint
Penalty
Summary
The facility failed to identify a concave mattress as a potential restraint for a resident and did not complete the necessary risk assessment, obtain written consent, or implement monitoring procedures. During an observation, a concave mattress was noted on the bed of a resident who was not present at the time. Interviews with staff members revealed that the mattress was used to prevent the resident from falling out of bed, as the resident had a history of falls and injuries related to a fracture from a fall at home, medication use, and changes in blood pressure. Despite these measures, the resident's medical record lacked documentation of a restraint risk assessment, consent, or monitoring for the use of the concave mattress prior to the survey date.
Failure to Provide Effective Foot Care for Diabetic Resident
Penalty
Summary
The facility failed to provide effective foot care for a diabetic resident, leading to a deficiency. During an observation and interview, a resident reported that her toenails were very long and curling, and she could not recall them being cut since her admission to the facility. Staff interviews revealed confusion about responsibility for scheduling podiatry appointments, with one staff member expressing discomfort in cutting the resident's nails due to her health conditions. Another staff member indicated that appointments should be documented in the resident's care plan, but a review of the resident's electronic health record showed no documentation of podiatry needs or appointments.
Trip Hazard and Hazardous Material Exposure in LTC Facility
Penalty
Summary
The facility failed to identify and mitigate a trip hazard by using a twin-size scoop mattress as a bedside fall mat for a resident. During an observation, the mattress was noted to be placed next to a resident's roommate's bed, and the resident reported that the mat was often moved to their side of the room, obstructing access to the restroom. The resident also mentioned witnessing a staff member trip over the mat, although no injury occurred. A staff member acknowledged the use of the mattress for fall prevention but expressed concerns about its size and difficulty in moving it, which could potentially lead to accidents. Additionally, the facility failed to protect a resident from hazardous materials by allowing them to keep a can of bug spray in their room. The resident reported informing the staff about bugs in the room, and management provided the bug spray for use. The spray was observed on the resident's dresser during multiple observations. The Safety Data Sheet for the spray indicated potential health risks, including skin and respiratory irritation, if not handled properly. Despite these risks, the facility permitted the resident to retain the spray in an accessible location.
Deficiencies in Dietary Management and Kitchen Sanitation
Penalty
Summary
The facility administration failed to hire and employ a Dietary Manager with the appropriate competencies and skills to manage the food and nutritional services effectively. Observations during a kitchen tour revealed several deficiencies, including a staff member serving food without a beard covering, grease and dust buildup on stove handles, and nonfunctional kitchen equipment. Additionally, there were mouse droppings in the food and chemical storage areas, and a bag of cake mix was found with a hole and mouse droppings inside. Items in the walk-in refrigerator were not labeled or dated, and there was a puddle of water on the kitchen floor without a wet floor sign. Interviews with staff members revealed that the facility dietitian did not schedule regular consultations or work directly with the dietary manager, who was promoted from within due to hiring challenges and had not completed a Certified Food Manager program. The facility had a contract dietitian who was available for consultation but had not met the dietary manager. A grievance was filed regarding bugs in the food, and staff acknowledged issues with mice in the kitchen. The facility had identified kitchen issues and included them in their QAPI process, with the last walk-through noting only minor issues.
Infection Control and Maintenance Deficiencies
Penalty
Summary
The facility failed to ensure enhanced barrier precautions were followed during wound care and medication administration through a feeding tube for a resident. During an observation, a staff member did not wear a gown while providing wound treatment to a resident's sacral pressure ulcer, incorrectly believing that gowns were only necessary for tube feedings and catheters. The same staff member also failed to wear a gown while administering medication through a feeding tube, acknowledging the oversight when questioned. Interviews with other staff members revealed that the facility had recently hired a new infection control preventionist who had conducted some observational audits. However, there was a discrepancy in understanding when gowns should be worn, despite ongoing training on enhanced barrier precautions. Additionally, the facility failed to repair a worn recliner in a resident's room, resulting in an uncleanable surface. Observations noted the recliner had wearing, tearing, and scratches, with material flaking off onto the floor. Despite the visible damage, no maintenance requests were provided by the end of the survey period. A staff member expressed uncertainty about the recliner's repair status and suggested it should be discarded, indicating a lack of communication or action regarding maintenance issues.
Failure to Maintain Kitchen Equipment
Penalty
Summary
The facility failed to ensure the safe and proper operation of essential kitchen equipment, including the oven, dessert refrigerator, cook's refrigerator, and ice machine. During an initial tour, it was observed that there were no paper towels in the dispensers near the sinks in the serving area, and the ice machine was warm with no ice present. The dessert refrigerator was also warm, containing several cans of unopened V8 juice. On a subsequent observation, the same issues persisted, with the addition of the ovens below the gas stove being non-functional and used for storage, and a sink behind the steam table having a plugged drain with standing water. Interviews with staff revealed that the equipment had been non-functional for an extended period, with the ice machine being the most recent to fail. Staff members indicated that issues were reported through the TELS system, but the maintenance logs from January 2024 to the present did not document which equipment was non-functional or any repairs made. This lack of documentation and unresolved equipment issues had the potential to affect any resident receiving food from the kitchen.
Latest citations in Montana
A resident with a history of hematuria, renal failure, anemia, and recent blood transfusions was readmitted from the hospital with discharge instructions to pause apixaban, but the facility failed to obtain admission orders and did not clarify the incomplete anticoagulant order. The resident’s care plan did not address anticoagulant use or monitoring, and staff administered multiple doses of apixaban after readmission. Nursing notes documented blood in the nephrostomy drainage bag on two days without provider notification or intervention, followed by worsening weakness, poor intake, and hypoxia that led to hospital transfer. Hospital records showed the resident had gross hematuria, hypotension, respiratory distress, acute kidney injury, and a critically low Hgb requiring transfusion, and a late entry note acknowledged that the discharge order to hold apixaban had been overlooked.
A resident who was cognitively intact but dependent for bowel and bladder care and limited in ROM reported that a specific staff member repeatedly left call lights unanswered for extended periods, causing the resident to soil briefs and then be pressured to ambulate to the bathroom and sign refusal-of-care forms. A family member corroborated long call-light waits and rude interactions, and staff noted the resident became anxious and displayed behaviors when care was forgotten or incomplete. Despite verbal reports, emails, and documentation at a care conference describing long call-light waits, incontinence episodes, and refusal forms used at night, no grievance was filed and the alleged neglect was not reported or investigated. The resident also developed unaddressed skin issues on the heels, coccyx, and ears, and +2 pitting edema in both feet and ankles, with offloading devices found unused in the room and no related wound orders or documented weekly skin assessments.
Multiple residents experienced inadequate pressure ulcer and skin care when staff failed to perform timely and accurate skin assessments, obtain and follow wound care orders, and implement appropriate care plan and nutritional interventions. One resident admitted with multiple skin issues developed a large, foul-smelling coccyx ulcer that was not promptly evaluated, lacked early wound orders, and was not reflected in the care plan or consistently documented on the TAR. Another resident with a coccyx pressure injury and a spinal incision had delayed wound measurements, late dietitian notification, missed daily wound treatments, and late addition of protein supplementation to the care plan. A resident using oxygen had painful, reddened ears and heel/eschar issues that were not captured in admission documentation, lacked wound orders, and had no subsequent skin assessments recorded. A further resident with a coccyx pressure ulcer had conflicting MDS staging and "present on admission" coding, along with numerous days where ordered daily wound care was undocumented or absent. Staff interviews revealed inconsistent weekly skin checks, missed admission skin evaluations due to EHR changes, limited dietitian availability, and wound care being performed by staff without formal wound training, all contrary to the facility’s own skin integrity policy.
The facility failed to thoroughly investigate, monitor, and document multiple abuse allegations involving staff-to-resident and resident-to-resident incidents. In one case, a resident reported that a staff member blew marijuana vape smoke in his face, but there was no related nursing documentation or post-incident monitoring. In another case, a resident reported being hit by another resident, was found with a red mark on the head, and was sent to the ER, yet nursing notes for both residents lacked documentation of the incident and follow-up monitoring. In a third case, a cognitively impaired resident with developmental delay was found in another resident’s room while that resident’s hands were being removed from inside the resident’s pants and shirt, after which the resident complained of pain and was sent to the ER; again, nursing notes for both residents contained no documentation of the event or post-incident monitoring, and the investigator did not fully interview or obtain written statements from all involved as required by facility policy.
The facility failed to thoroughly investigate multiple allegations of abuse and neglect, including one resident’s report that a staff member was verbally demeaning and rushed her during oral care, and another resident’s report of inadequate ADL care with prolonged call light response times and being left in a soiled brief. A staff member admitted not reporting or investigating the latter allegation, and no related documentation was produced. In a separate incident, a resident alleged a CNA turned off the call light and refused requested personal care; the facility interviewed only the involved staff and did not interview other residents who might also have experienced call lights being turned off without care being provided, despite a witness stating this was a common practice by multiple staff. Additional requested interviews and information were not provided to surveyors.
Surveyors found that the facility failed to complete timely and comprehensive baseline care plans for three newly admitted residents. One resident with multiple serious conditions and a coccyx wound had no baseline care plan addressing wound care, pain, or chronic conditions for several days after admission. Another resident with dysphagia, dementia, and documented skin issues on the buttocks, heels, and knee had a baseline care plan that did not identify pressure wounds or related treatments. A third post‑surgical resident with a Stage 3 pressure ulcer and a lumbar incision had a baseline care plan that omitted wound management and post‑operative pain control. A staff member reported that baseline care plans are only generated after the admission nursing assessment is completed and locked, and acknowledged they are not always completed on time.
A resident’s long-time friend, a former employee previously terminated over an abuse allegation, was barred from entering the facility when she attempted to visit, and was told law enforcement would be called if she returned. Another individual confirmed awareness of the restriction, expressed no concern about the friend abusing the resident, and stated that the facility did not offer supervised or common-area visits. A staff member reported that any former employee terminated for an abuse allegation was categorically prohibited from returning to the building, without considering the resident’s relationship with the visitor, despite a visitation policy stating residents have the right to receive visitors of their choice and allowing only limited or supervised access when abuse is suspected or found.
The facility failed to follow its grievance policy by not documenting or investigating a grievance request from a resident and family member alleging that a CNA ignored call lights for extended periods, failed to provide timely ADL care, forced ambulation to the bathroom at night, and pressured the resident to sign refusal-of-care forms, causing the resident to feel afraid and neglected. In a separate case, the facility did not adequately investigate or document a grievance from a dependent, mobility-impaired resident who reported that a male CNA was rough and refused to reposition his contracted legs for comfort, and the staff member assigned to the investigation did not identify the CNA involved or record her explanation of the situation on the grievance form.
A resident reported that a former staff member repeatedly left the call light unanswered for extended periods, did not provide needed ADL assistance, and encouraged the resident to sign refusal-of-care forms, resulting in the resident soiling briefs before being asked to ambulate to the restroom. Another staff member stated that no care concerns had been brought to their attention and acknowledged that the alleged abuse and neglect were not reported. When surveyors requested IDT notes, root cause analysis, reporting, and investigation documents related to the staff member and this resident, the facility was unable to provide any documentation, indicating the allegation was not timely reported to the State Survey Agency or investigated.
Surveyors found that several residents did not receive appropriate ADL and hygiene assistance or accurate documentation of those services. A dependent resident reported inconsistent help with meals, only sponge baths instead of showers for several weeks, lack of shaving, and prior grievances about staff not assisting with a urinal or repositioning his legs. Another cognitively intact resident, dependent for oral care and dressing, stated he was not offered mouthwash or a warm washcloth, and staff confirmed they had never offered mouthwash despite charting that personal hygiene was provided. A third resident, largely independent with self-care, reported that washcloths were not available unless requested, and no washcloths were seen in the room, while documentation showed staff performing most of her personal hygiene. These findings showed failures to offer basic hygiene items and to accurately document ADL care provided.
Failure to Clarify Anticoagulant Orders Leads to Unnecessary Drug Administration and Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s drug regimen was free from unnecessary drugs when nursing staff did not clarify and correctly implement anticoagulant orders upon the resident’s readmission. The resident had been hospitalized for hematuria, renal failure, and anemia, received multiple blood transfusions, and was discharged back to the facility with an After Visit Summary instructing that apixaban (an anticoagulant) be paused, with no restart date specified. Despite this, the facility’s admission documentation for the readmission date showed no admission orders, and the apixaban order was not clarified with the physician. The medication was restarted and administered after readmission, even though the hospital documentation indicated it was to be paused and later discontinued. Following readmission, the resident’s Medication Administration Record showed that seven doses of apixaban were given. The resident’s care plan, initiated on the readmission date, did not identify any problems, goals, or interventions related to anticoagulant use, safety, or monitoring for side effects. Nursing progress notes documented that the resident had a right-sided nephrostomy with yellow urine drainage on the day of readmission, and then documented blood in the nephrostomy drainage bag on two consecutive days. However, there was no documentation that the provider was notified about the hematuria or that any action was taken in response to this change. Subsequently, nursing notes described the resident as weak, not eating, unable to maintain a sitting position, and having low oxygen saturation that did not adequately improve with increased supplemental oxygen, leading to transfer to the emergency department. Hospital records from that visit showed the resident presented with hypoxia, hypotension, profound weakness, respiratory distress, gross hematuria, acute kidney injury, and a critically low hemoglobin of 6.9 g/dL, and that the resident had received an anticoagulant and required blood transfusions. A late entry nursing note at the facility later documented that the hospital discharge summary had been overlooked, the order to hold apixaban was not implemented, and the resident continued to receive apixaban until readmission to the hospital. The facility’s root cause analysis attributed the event to ambiguity in discharge communication and medication reconciliation workflow and noted that the apixaban order was incomplete and not clarified before administration.
Failure to Identify and Address Neglect, Call-Light Delays, and Skin Concerns
Penalty
Summary
The deficiency involves the facility’s failure to identify, report, and address neglect of care concerns for a cognitively intact resident who was dependent on staff for bowel and bladder care and had range of motion limitations in both upper and lower extremities. The resident reported that a specific staff member (NF7) repeatedly left his call light on for extended periods, often over 45 minutes and up to hours at night, resulting in him soiling his brief with bowel and bladder incontinence while waiting for assistance. When staff eventually responded, NF7 would attempt to have the resident ambulate to the restroom despite the resident already being incontinent, and would then encourage him to sign refusal of care forms when he declined. The resident described being upset, anxious, and irritable, and stated he usually “peed” and “soiled” his pants and developed skin issues from sitting so long without being cleaned. A family member (NF6) corroborated concerns about long call light response times, stating the resident’s call light was left on for over an hour, leading to incontinence episodes, and that NF7 spoke to the resident in a rude and angry manner. NF6 reported these concerns in person, by phone, and by email to facility staff, including staff members A and C. Staff member O reported that the resident had anxiety and behaviors that were exacerbated when staff forgot about him or failed to perform all required care. Despite these reports and the resident’s expressed fear and anxiety when NF7 was working, no staff member asked the resident if he felt safe or explored what had occurred on nights with or without NF7, and the alleged neglect was not reported or investigated by facility leadership. The resident also had unaddressed skin concerns and edema that were not properly identified or managed. Staff member B stated weekly skin assessments should have been done but that wound care staff were unaware of any ear or coccyx issues, and the physician orders lacked wound orders for the resident’s left heel. On assessment, staff member P observed eschar on the left heel that appeared to need debridement, redness and cracking on the right heel, pink coccyx, and reddened ears, with delayed capillary refill on one ear, as well as +2 pitting edema in both feet and ankles that had developed during the resident’s stay. Posey boots intended to offload the heels were found in the resident’s cabinet, and staff member P stated she had never seen them used on the resident. Additionally, at a care conference documented and signed by staff member C, the resident reported waiting 20–40 minutes for call lights at night, having accidents while waiting, and being made to sign refusal papers when he declined to go to the bathroom after already being wet. Despite this documentation of neglect-related concerns, no grievance was filed, and staff members B and C stated they were unaware of or did not report or investigate any alleged abuse or neglect for this resident.
Failure to Assess, Document, and Treat Pressure Ulcers and Related Skin Conditions
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain an effective system for pressure ulcer prevention, identification, assessment, and treatment for multiple residents. For one resident admitted with existing skin issues on the buttocks, both heels, and a right knee wound, nursing notes documented a silicone foam dressing on the coccyx that was saturated with foul-smelling brown-yellow drainage, and a non-stageable pressure ulcer with slough, black eschar, and a large reddened border. This was the first detailed description of the coccyx pressure ulcer, and there were no wound care orders in the chart at that time. A subsequent weekly skin evaluation described a large, deep coccyx wound with copious foul-smelling drainage and extensive slough and granulation tissue, but incorrectly listed that date as the first observation despite the wound being identified nine days earlier. Wounds on the left heel, right outer ankle, and right knee were not evaluated until several days after admission, and the right heel was never evaluated during the stay. The resident’s care plan did not identify pressure ulcers as a problem and contained no interventions for pressure ulcer care or nutrition to support wound healing, and the treatment administration record showed wound treatments were not ordered until several days after admission and were then not consistently documented as completed. Another resident was admitted with a coccyx area that was open and possibly caused by pressure, and a late entry note identified a Stage 3 pressure ulcer to the coccyx from admission. However, the nutrition evaluation form later indicated “no” to the presence of a pressure injury and instead listed “other skin condition,” even though coccyx wound care was ordered. The weekly skin evaluation documented the first observation and measurements of the coccyx wound two weeks after admission, and the dietitian was not notified until several days after that. The treatment record showed that daily wound care orders for both the coccyx pressure ulcer and a surgical spine incision were not carried out on at least two days. Nutritional interventions to support wound healing, including a protein supplement, were not added to the care plan until more than two weeks after the wound was identified. Staff interviews revealed that the dietitian was only present in the facility limited hours on two days per week, that residents admitted later in the week might not be assessed nutritionally until the following week, and that a fourteen-day delay in nutritional assessment, while allowed, was acknowledged as not best practice for residents with wounds. A third resident using oxygen reported pain behind both ears, and observation showed that oxygen tubing protectors had slid out of place, leaving the ears unprotected. The right ear was red where the tubing rested, and the left ear was very red with a whitish substance in the crease. Staff later described this resident’s skin as having eschar on the left heel that appeared to need debridement, a red and cracked right heel, a pink coccyx, and reddened ears, with the left ear showing slower capillary refill. The facility’s records contained no wound orders for the left heel, no skin assessments since the most recent readmission, and an admission nursing evaluation that documented the skin as warm, dry, intact, and without wounds. A fourth resident had a coccyx pressure ulcer that was present on admission and gradually decreasing in size according to wound assessments. However, MDS assessments contained inconsistent documentation: one assessment showed no unhealed pressure ulcers on admission, a later discharge assessment documented a Stage IV pressure ulcer present on admission, and a subsequent quarterly assessment documented a Stage III pressure ulcer not present on admission. Treatment administration records showed no coccyx wound treatment in one month, initiation of daily wound care late in the following month with at least one missed documented treatment, and in the next month, daily wound care orders with more than half of the scheduled treatments lacking documentation of completion. In the subsequent month, the TAR failed to show any wound care performed for the coccyx pressure ulcer. Staff interviews indicated that weekly skin checks were the facility practice but were not consistently completed, that nurses were not always coding or documenting wounds correctly, and that admission skin evaluations were sometimes not done due to issues with a new computer system. A staff member performing wound care on one resident’s coccyx reported having no formal wound training and described a wound bed fully covered with thick yellow-tan slough, which, according to the cited National Pressure Ulcer Advisory Panel guideline, could not be accurately staged, despite the facility’s practice of staging it as a Stage III pressure ulcer. The facility’s own Skin Integrity policy required that upon admission, the licensed nurse establish a plan of care based on risk factors or presence of wounds, conduct ongoing weekly full-body skin audits, document new skin impairments with detailed characteristics and measurements, record qualifying wounds on the weekly skin evaluation form, notify the medical provider and obtain treatment orders, notify the resident or representative, notify the registered dietitian, and implement and document appropriate care plan interventions. The findings across these residents showed that these policy steps were not consistently followed: admission and weekly skin evaluations were missed or delayed, wounds were not accurately or timely documented or staged, treatment orders were delayed or not consistently carried out, nutrition and care plan interventions for wound healing and prevention were not promptly implemented, and staff responsible for wound care sometimes lacked formal wound training.
Failure to Thoroughly Investigate and Document Multiple Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to complete thorough investigations, monitoring, and documentation for multiple abuse allegations. In one incident, a resident reported that a staff member blew marijuana vape smoke in his face. The staff member later admitted to vaping marijuana in the resident’s room. Despite this, the resident’s nursing progress notes for the period following the incident contained no documentation of the event or any post-incident monitoring, and the psychosocial impact assessment tool indicated that no ALERT charting had been done by nursing or social services. In a second incident, a resident sitting in a wheelchair by the nurse’s station told a staff member that another resident had hit him; assessment revealed a red mark on the resident’s head, and the resident was sent to the emergency room at the family’s request. However, nursing progress notes for both the alleged victim and the alleged aggressor for the days following the incident contained no documentation of the incident or any post-incident monitoring. The staff member responsible for the investigation stated that he relied on video footage and interviews with the two residents, but these interviews were only documented in the incident report, and no other staff or residents on shift were interviewed. In a third incident, staff found one resident in another resident’s room and observed the second resident removing his hands from inside the first resident’s pants and shirt; the first resident later stated, “It hurts down there,” and was sent to the emergency room. The first resident had diagnoses including unspecified symptoms involving cognitive functions and awareness, anxiety, depression, cerebral infarct, and was described as having a developmental delay with the mentality of an 8-year-old, while the second resident was cognitively intact based on a BIMS score of 14. Nursing progress notes for both residents for the days following the incident contained no documentation of the event or any post-incident monitoring. The staff member overseeing the investigation acknowledged that he did not document his post-incident checks, did not interview staff on shift or other residents, and no abuse education or protective measures for staff were documented, contrary to the facility’s abuse prevention policy that requires interviews with all involved, retrieval of written statements, and documentation of assessments and monitoring.
Failure to Thoroughly Investigate Allegations of Abuse and Neglect
Penalty
Summary
The deficiency involves the facility’s failure to fully investigate multiple allegations of abuse and neglect, including not identifying all potentially affected residents. One resident reported that a staff member (NF8) was “nasty and pushy” while assisting with oral care, telling her she should not take so long brushing her teeth because she only had eight teeth and making her hurry without giving her the time she needed. When the facility questioned NF8 about this incident, he resigned from his position. Review of the facility-reported incident showed no staff interviews were completed as part of the investigation, despite the importance of such interviews in understanding the incident and identifying root causes. Another resident reported inadequate ADL care by staff member NF7, including long call light response times and being left in a soiled brief for hours, and stated he had reported these concerns to facility staff. A staff member later stated they were unaware of any concerns from the resident or his family regarding NF7 and acknowledged they did not report or investigate the alleged abuse or neglect. When surveyors requested documentation such as interdisciplinary team notes, root cause analysis, reporting, and investigation related to concerns with NF7, none was provided. In a separate facility-reported incident, a resident alleged a CNA turned off the call light and refused to provide requested personal care. The facility interviewed only the staff involved that night and did not interview other residents who might have been affected by staff turning off call lights without providing care. A witness (NF5) reported that it was the facility’s usual practice to turn off call lights without providing help, that staff often told the resident they would return but did not always do so, and that multiple staff engaged in this behavior. Despite a request from surveyors, the facility did not provide additional resident interviews or information regarding this allegation by the end of the survey.
Failure to Complete Timely Baseline Care Plans for Wounds and Pain Management
Penalty
Summary
The deficiency involves the facility’s failure to complete timely and comprehensive baseline care plans that provided instructions for resident-centered care for three residents. One resident was admitted with multiple serious diagnoses, including acute kidney failure, anemia, atrial fibrillation, chronic respiratory failure, hypertension, a right femur fracture, morbid obesity, and muscle weakness. A nurse progress note documented a coccyx wound described as stage I open on the day of admission, yet no baseline care plan was initiated to direct staff in caring for the wound, managing pain, or addressing the resident’s chronic medical conditions. A care plan was not started until several days later, and when it was initiated, it only addressed advanced directives, oral/dental health problems, loneliness, and discharge planning, without including wound or pain management. Another resident was admitted with dysphagia, dementia, behaviors, a history of falls, and a urinary tract infection. Nursing progress notes documented skin issues on the buttocks, both heels, and the right knee, but the baseline care plan initiated the same day did not identify pressure wounds or any treatment for those wounds. A third resident, admitted after surgical repair of a lumbar 4 compression fracture, had a documented Stage 3 pressure ulcer and a lower back incision with intact staples on the admission nursing evaluation. However, the baseline care plan for this resident did not include wound management interventions or pain management for post-operative pain. During an interview, a staff member explained that the baseline care plan is triggered when the admitting nurse completes and locks the admission nursing assessment, and acknowledged that when assessments are not locked, baseline care plans are not completed and are not always done on time.
Failure to Honor Resident’s Right to Chosen Visitor
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to receive visitors of her choosing. A long-time friend of the resident, identified as NF1, reported that when she first attempted to visit the resident after the resident’s admission, staff member B escorted her out of the building and told her that law enforcement would be called if she returned. NF1 had previously been employed by the facility approximately four years earlier and had been terminated due to an allegation of abuse toward a resident. The facility did not allow her to visit the resident in any capacity. Another individual, NF2, stated he was aware that the facility was not allowing NF1 to visit the resident and that he knew about the prior abuse allegation but was not concerned about NF1 abusing the resident. NF2 stated he wanted NF1 to be allowed to visit and that the facility did not offer supervised visits or visits in a common area. He was hesitant to raise the visitation issue with the facility because he was concerned it might change how the resident was treated. Staff member B confirmed that any employee terminated due to an abuse allegation was not allowed to return to the building for any reason, and that this restriction was applied without considering the resident’s history with the visitor. The facility’s visitation policy stated residents have the right to receive visitors of their choice and that limitations may include denying or limiting access to individuals suspected of abuse until an investigation is completed or abuse is found, but the facility applied a blanket prohibition in this case.
Failure to Document and Investigate Resident Grievances Alleging Neglect and Inadequate Repositioning
Penalty
Summary
The deficiency involves the facility’s failure to follow its grievance policy and to ensure residents could voice grievances related to alleged abuse and neglect without discrimination or reprisal. One resident reported that a specific CNA (NF7) left his call light on for hours, did not assist with ADLs, and that this led to bowel and bladder incontinence while he waited for help at night. The resident stated that when the CNA finally responded, the CNA would force him to ambulate to the restroom instead of cleaning him in bed, and when the resident refused to ambulate, the CNA told him to sign a refusal of care form. The resident reported being afraid of this CNA and feeling neglected in his care, and he stated he reported these concerns to staff member C. An external email from NF6 to staff member C documented that the resident was afraid of NF7, described NF7’s statements about his job duties, and explicitly requested to file a grievance and have NF7 kept away from the resident. Additionally, a care conference note signed by staff member C documented the resident’s report of being made to sign refusal sheets at night and waiting 20–40 minutes for call lights to be answered. Despite this, staff member C, identified as the grievance official, stated there were no concerns brought forth from the resident or family regarding NF7, and no grievance was completed for this abuse/neglect allegation as required by the facility’s grievance policy. The deficiency also includes the facility’s failure to thoroughly investigate and document findings for another resident’s grievance regarding care. This resident, who had impaired mobility in both upper and lower extremities and was dependent for all ADLs except eating, reported that a night CNA was rough and refused to reposition his legs, and he stated he had complained to the facility but the issue continued. A written grievance from this resident documented that a male CNA would not readjust his legs for comfort. The grievance form’s investigative findings did not show any attempt to identify the specific night CNA involved or to clarify what care was being refused. Staff member E, who was responsible for investigating this grievance, could not recall details of the investigation and acknowledged she did not attempt to identify the accused CNA, characterizing the issue as a recurrent complaint and a miscommunication about repositioning due to the resident’s leg contractures. She stated she had encouraged the resident to be more specific about the repositioning requested but could not explain why this was not documented on the grievance form. The facility’s grievance policy required that grievances, including those involving abuse or neglect, be documented on a grievance form and investigated, but this was not done in accordance with policy for these residents’ complaints.
Failure to Timely Report Alleged Abuse and Neglect to State Agency
Penalty
Summary
The facility failed to timely report an allegation of abuse and neglect to the State Survey Agency involving one sampled resident, identified as resident #47. During an interview, resident #47 reported that a specific former staff member, NF7, would leave his call light on for hours, fail to assist with ADL care, and this lack of response resulted in the resident soiling his brief with bowel and bladder because he waited so long for help. The resident further stated that NF7 would encourage him to sign a refusal of care form and then expect him to ambulate to the restroom after he had already gone in his brief. In a separate interview, staff member B stated that no care concerns from the resident or family had been brought to their attention and acknowledged that they did not report the alleged abuse or neglect of care. A request by surveyors for documentation related to resident #47’s interdisciplinary team notes, any identified root causes, reporting, and investigation of concerns involving NF7 and resident #47 yielded no documentation by the end of the survey, demonstrating a lack of evidence that the allegation was reported or investigated as required.
Failure to Provide and Accurately Document ADL and Hygiene Assistance
Penalty
Summary
Surveyors identified that the facility failed to provide and accurately document assistance with activities of daily living (ADLs) for multiple residents. One resident, who was assessed on the MDS as dependent for all ADLs except eating (requiring only partial to moderate assistance with eating), reported not always receiving help with meals, having only sponge baths for several weeks instead of showers, and needing a shave while observed lying in bed in a hospital gown with several days of facial hair growth. This same resident had previously filed a grievance stating that a night nurse would not assist with use of a urinal despite his inability to do this himself, and that a male CNA would not readjust his legs for comfort. These findings showed a lack of consistent ADL assistance for a resident documented as dependent. Surveyors also found failures related to personal hygiene supplies and documentation for two other residents. One cognitively intact resident, dependent for oral hygiene and dressing, stated he had not been offered mouthwash or a warm washcloth to wash his face that day, and no mouthwash was present in his room; staff later confirmed they had never offered him mouthwash, despite documentation that personal hygiene was offered and that staff did most of the activity. Another resident, who stated she could wash her face, brush her teeth, and comb her hair mostly independently, reported that washcloths were never available unless she specifically asked staff, and on observation there were no washcloths in her room. Her EHR documentation showed staff did most of her personal hygiene activity, while staff later stated she was generally independent and that they had not been giving her a daily washcloth. These discrepancies demonstrated inaccurate ADL documentation and failure to routinely offer basic hygiene items such as washcloths and mouthwash.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
