Awe Kualawaache Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Crow Agency, Montana.
- Location
- 10131 S Heritage Rd, Crow Agency, Montana 59022
- CMS Provider Number
- 275153
- Inspections on file
- 22
- Latest survey
- May 13, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Awe Kualawaache Care Center during CMS and state inspections, most recent first.
The facility failed to ensure the infection preventionist was adequately trained and knowledgeable, did not maintain documentation of infection control audits, and lacked a comprehensive water management program to prevent Legionella. Staff did not consistently follow proper transmission-based precautions for a resident with C. diff, and a nurse did not perform hand hygiene between glove changes during wound care. These deficiencies increased the risk of infection for all residents.
The facility did not notify the State Ombudsman Office or provide required ombudsman contact information to residents during hospital transfers or discharges. Staff interviews revealed a lack of awareness about these requirements, and review of transfer/bed hold notices for several residents confirmed the omission. The facility was unable to provide documentation of ombudsman notification for these events.
A resident in a LTC facility was physically restrained for an hour without following proper procedures. The charge nurse directed staff to restrain the resident to administer an antipsychotic injection due to aggressive behavior. The facility failed to obtain a practitioner's order, ensure the least restrictive restraint, and provide ongoing monitoring, violating F604 - Restraints guidelines.
A facility failed to update a resident's care plan to include his preference for male staff who spoke his native Crow language, which reduced his agitation and aggression. Despite staff awareness and discussion of this preference, it was not documented in the care plan, leading to a deficiency in personalized care.
A facility failed to ensure nursing staff were adequately trained and competent in managing a resident with aggressive behaviors and the use of restraints. A resident was physically restrained for an hour without proper oversight after an intramuscular antipsychotic injection. The nurse involved was a new graduate, and staff reported a lack of training in restraint use, with no documentation of training in their personnel files.
The facility's assessment failed to accurately reflect the care required for residents with behavioral health needs, as staff expressed concerns about their ability to manage aggressive behaviors. Despite the facility's claims of offering mental health services, interviews revealed a lack of appropriate skills and resources to care for these residents.
The facility failed to provide adequate behavioral health training for staff, leading to unawareness of care plan interventions for residents with aggressive behaviors. Staff expressed uncertainty in handling incidents, with some relying on seeking help from the DON or other nurses. Residents with known behavioral issues, such as one with paranoid schizophrenia, were monitored by sitters who were not informed or trained on managing behaviors. The lack of training and awareness contributed to the deficiency identified by surveyors.
A resident was involved in a physical altercation with a CNA, who aggressively pulled the resident's hands behind her back and pulled her to the ground. The incident was captured on security footage, showing the resident pushing her walker towards the CNA, who then restrained and pulled the resident down, despite other staff attempting to de-escalate the situation. The CNA was identified as easily angered and a bully, leading to their removal and termination.
The facility failed to assess the root causes of a resident's behavioral outbursts and did not provide necessary mental health services for another resident with schizophrenia. One resident exhibited aggression without root cause assessments, while another lacked documentation of receiving required outpatient mental health services. Staff reported challenges in coordinating care with the only available provider.
A facility failed to limit PRN psychotropic medications to 14 days or provide documented rationale for extended use. A resident received Ativan and Olanzapine without physician documentation for continued use or stop dates. Staff indicated the physician visited monthly and pharmacy reviews for stop dates were pending.
The facility failed to update the care plan for a resident with a chronic non-pressure ulcer and did not include daily weight monitoring as instructed by an emergency room physician. Staff interviews revealed that care plan updates were delayed due to the resignation of the previous DON.
The facility failed to ensure nurse competencies for wound care, resulting in a resident with diabetes and chronic ulcers not receiving necessary treatments for several days. The admitting physician's orders were incomplete, and the wound clinic could not be contacted over the weekend and holiday for clarification.
The facility failed to accurately submit PBJ data for RN coverage and 24-hour licensed nurse coverage for multiple days in Quarter One of Fiscal Year 2024. Discrepancies were found between the submitted data and employee timecards, and staff interviews revealed that the data was based on outdated schedules.
Infection Control Deficiencies: Training, Waterborne Illness Prevention, and PPE Compliance
Penalty
Summary
The facility failed to ensure that the infection preventionist was properly trained and knowledgeable in key infection control practices. The infection preventionist reported not receiving the required education for the position, was unable to provide documentation of hand hygiene and PPE audits, and was unsure about the frequency of mandatory infection control education. Additionally, the infection preventionist did not have quick reference materials for determining appropriate precautions for specific infections, was uncertain about which diseases were reportable to the state, and incorrectly stated that alcohol-based hand rubs were preferable to handwashing for Clostridioides difficile (C. diff) cases, contrary to CDC guidance. The facility also failed to implement and document safety measures to prevent waterborne illnesses such as Legionella. Staff interviews revealed that there was no log of toilet flushing or clear understanding of the requirements for weekly flushing to prevent Legionella growth. Testing for Legionella was limited to swab testing a countertop in the kitchen, and there was no evidence of a comprehensive water management program as outlined in facility policy, including monitoring, control limits, and documentation. Deficiencies were also observed in the application of transmission-based precautions and hand hygiene. One resident with C. diff was placed on droplet precautions, but staff entered the room without appropriate PPE, left the door open, and were unclear about the correct precautions. Another staff member failed to perform hand hygiene between glove changes while providing wound care to a resident, despite facility policy requiring handwashing after glove removal. These lapses in infection control practices had the potential to affect all residents in the facility.
Failure to Notify State Ombudsman and Provide Contact Information During Resident Transfers
Penalty
Summary
The facility failed to notify the State Ombudsman Office when residents were transferred to the hospital or discharged, and did not provide residents with the required contact information for the State Ombudsman Office. This deficiency was identified for three sampled residents who experienced transfers or discharges, as their transfer/bed hold notices lacked the necessary ombudsman contact details. Staff interviews revealed a lack of awareness regarding the requirement to notify the ombudsman and to include their contact information on transfer/discharge forms. Additionally, the facility was unable to provide documentation showing that the ombudsman had been notified of these transfers or discharges. Facility policy indicated that notice of transfer or discharge should be provided to the resident, their representative, and the LTC ombudsman when practicable. However, review of the records for the affected residents showed that this policy was not followed, as the required notifications and contact information were missing. Staff confirmed that notification to the ombudsman was only done in specific circumstances, such as incident reports, and not routinely for all transfers or discharges.
Improper Use of Physical Restraints on Resident
Penalty
Summary
A deficiency was identified in a long-term care facility where a resident was physically restrained without following the required procedures. The incident involved a resident who was acting aggressively towards staff and other residents. The charge nurse directed staff to physically restrain the resident to administer an intramuscular injection of an antipsychotic medication. The restraint continued for an hour, which exceeded the initial 15 minutes intended for the medication to take effect. The staff did not ensure the least restrictive restraint was used, nor did they verify with the nurse if it was safe to continue restraining the resident. The facility failed to follow the necessary steps outlined in the State Operations Manual, Appendix PP, under F604 - Restraints. These steps include obtaining an order from a practitioner during or immediately after the application of the restraint, ensuring the restraint is a last resort, and providing ongoing monitoring and assessment of the resident's condition. Additionally, the facility did not document the incident properly, including the resident's behavior, interventions attempted, and whether the use of a physical restraint was ordered by a practitioner. Interviews with staff members revealed that the charge nurse did not verify the least restrictive method of restraint and did not ensure continuous monitoring of the resident's condition. The staff members involved in the restraint did not consistently apply the restraint and failed to assess other interventions that could address the resident's aggressive behavior. The facility did not take steps to address future potential episodes of imminent danger involving the resident.
Failure to Update Care Plan with Resident's Language and Gender Preferences
Penalty
Summary
The facility failed to update a resident's individualized care plan to reflect personal preferences related to communication and the provision of Activities of Daily Living (ADL) care. Specifically, the care plan did not include the resident's preference for male staff who could speak his native Crow language, which was observed to reduce his agitation and aggression. During an observation, the resident was seen interacting positively with a male staff member who spoke his native language, indicating that this preference was beneficial for his well-being. Interviews with staff members revealed that the resident's preference for male Crow-speaking staff was known and discussed during the facility's daily meetings. However, this preference was not documented in the resident's care plan, which was last revised on 11/18/24. Staff acknowledged the oversight and mentioned that they were working on improving the development of individualized care plans. The omission of this critical information in the care plan led to a deficiency in providing personalized care that could potentially mitigate the resident's aggressive behaviors.
Inadequate Training and Oversight in Restraint Use
Penalty
Summary
The facility failed to ensure that all nursing staff working with a resident who exhibited aggressive behaviors were adequately educated and competent to provide necessary services for the resident's needs, particularly concerning behaviors and the use of restraints. On a specific incident, a charge nurse directed staff to physically restrain a resident who was aggressive towards staff and other residents. The restraint was applied to administer an intramuscular antipsychotic injection, and staff were instructed to continue restraining the resident for an additional 15 minutes to allow the medication to take effect. However, the resident was restrained for a total of one hour without proper nursing oversight or reassessment, as the charge nurse did not reassess or document the resident's condition every 15 minutes during the restraint period. Interviews revealed that the nurse involved was a new graduate who had just passed her nursing boards and was having difficulty managing the situation. Staff members involved in the restraint reported a lack of training on how to restrain a resident, with one staff member indicating it was his first time having physical contact with a resident. The facility's records failed to show documentation of training or education regarding resident care or restraint use for the staff involved. The incident highlighted a deficiency in ensuring that nursing staff had the appropriate competencies to manage residents with aggressive behaviors and the proper use of restraints.
Inadequate Behavioral Health Care Assessment
Penalty
Summary
The facility failed to review and update its facility-wide assessment to accurately reflect the care required for residents with behavioral health needs. This deficiency was identified through interviews and record reviews, revealing that the facility's assessment did not consider the specific needs of residents with aggressive behaviors. Staff members expressed concerns about their ability to manage these behaviors, indicating a lack of appropriate skills and resources. The facility's assessment, dated 12/13/22, claimed to offer services for mental health and behavior management, but staff interviews contradicted this claim, highlighting a gap between documented capabilities and actual practice. During interviews, staff members expressed their inability to care for residents with behavioral health needs adequately. One staff member mentioned that a resident required a one-to-one sitter due to behaviors and was awaiting a psychological evaluation. Another staff member, new to the facility, was unaware of the facility assessment's claims regarding behavioral health care. Additionally, a staff member reported that there were seven residents with aggressive behaviors on the unit, and the CNAs lacked the skills to manage these behaviors effectively. These findings indicate a significant discrepancy between the facility's stated capabilities and the actual care provided to residents with behavioral health needs.
Inadequate Behavioral Health Training for Staff
Penalty
Summary
The facility failed to provide adequate behavioral health training for staff, which was inconsistent with the needs of the residents. During observations and interviews, it was revealed that staff members were not aware of the specific behaviors or care plan interventions for residents with aggressive behaviors. Staff members expressed uncertainty about how to handle aggressive incidents, with some stating they would seek assistance from the Director of Nursing or other nurses. The lack of training and awareness of care plans was evident among multiple staff members, who were responsible for monitoring residents with known behavioral issues. Resident #2, who has a history of paranoid schizophrenia and aggressive behavior, was observed to have a sitter who was not informed about the resident's past behaviors or trained on how to manage them. The care plan for Resident #2 included non-pharmacologic interventions and monitoring, but staff were unaware of these interventions and did not know the resident's triggers. Similarly, Resident #3 exhibited aggressive behaviors during care activities, and staff reported feeling overwhelmed and untrained to manage such behaviors effectively. The facility's documentation, including care plans and progress notes, indicated a lack of identification of triggers and root causes for the residents' behaviors. Staff interviews highlighted a general feeling of burnout and inadequacy in handling aggressive behaviors, with some staff expressing fear of potential abuse incidents due to the facility's inability to manage such residents. The absence of a structured training program for managing behavioral health needs contributed to the deficiency identified by the surveyors.
Failure to Prevent Resident Abuse by Staff
Penalty
Summary
The facility failed to prevent resident abuse involving a physical altercation between a resident and a staff member. The incident involved a resident and her assigned one-on-one Certified Nursing Assistant (CNA) in the doorway to the dining room. The CNA was observed pulling the resident's hands behind her back in an aggressive manner and subsequently pulling the resident to the floor. This altercation was captured on security camera footage, which showed the resident walking into the dining room with her walker, followed by the CNA at a distance. The resident turned and pushed her walker towards the CNA, who then grabbed the resident by her arms, turned her around, and pulled her to the ground, despite other staff members arriving to help de-escalate the situation. Interviews revealed that the staff member involved, identified as easily angered and a bully, was removed from the shift and later terminated. The incident was reported to a staff member who reviewed the security footage and began an investigation.
Failure to Assess Behavioral Outbursts and Provide Required Mental Health Services
Penalty
Summary
The facility failed to assess the root cause or triggers of behavioral outbursts for one resident and did not provide the necessary behavioral health services for another resident as outlined in their PASRR Level II. Resident #2 exhibited a pattern of agitation and aggression, including assaulting another resident and aggressive behavior towards staff. Despite these incidents, no root cause assessments were conducted to identify trends or triggers. Staff interviews revealed that the facility was advised to send the resident to the emergency room during a crisis, but logistical challenges made this difficult. Additionally, attempts to find new placements for the resident were unsuccessful due to her behaviors. Resident #4, who had a history of schizophrenia and required specialized outpatient mental health services, did not have any documentation in their electronic medical record indicating they were receiving or refusing these services. Staff reported ongoing difficulties in coordinating behavioral health services with the only available provider in the area. During the exit conference, it was noted that the facility intended to send the requested behavioral health documentation to the State Survey Agency, but no documentation was received.
Failure to Limit PRN Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that PRN psychotropic medications were limited to 14 days or had documented rationale for extended use, and did not ensure that PRN antipsychotic drugs were renewed only after evaluation by a physician. A resident had PRN orders for Ativan and Olanzapine, both starting on July 1, 2024. The resident received Ativan seven times and Olanzapine twice in July, but there was no physician documentation justifying the continued PRN use of these medications, nor were there stop dates listed. Staff member B indicated that the physician visited the facility once a month and was otherwise available by phone, and that pharmacy reviews to catch stop dates had not been completed for July 2024.
Failure to Update Care Plan for Wound Care and Daily Weights
Penalty
Summary
The facility failed to revise and update the care plan for a resident with a chronic non-pressure ulcer on the right lower extremity. Despite a physician's order to clean the wound and apply specific treatments, the care plan did not include these interventions. Additionally, after the resident was seen in the emergency room for excess fluid retention, the emergency room physician instructed the facility to weigh the resident daily, but this intervention was also not added to the care plan. Interviews with staff revealed that care plan conferences and updates were not completed following the resignation of the previous Director of Nursing, leading to a backlog in care plan updates and meetings.
Failure to Ensure Nurse Competencies for Wound Care
Penalty
Summary
The facility failed to ensure that the nurse competencies and skills were sufficient to provide wound care services for a resident with diabetes and chronic ulcers. The resident's electronic medical record showed an admission diagnosis of diabetes Type 2 with other skin ulcer and a non-pressure chronic ulcer of the right lower leg. The physician's admission order included an order for Gentamicin Sulfate ointment to be applied once a day, but it did not specify which wound was to be treated. The treatment record showed that the wound treatment was not completed on three consecutive days, and there was no documentation explaining why the treatments were not completed. Additionally, the medical records did not show any attempt to contact a medical provider to clarify the wound care orders during this period. A late entry nursing progress note indicated that the orders were hard to read and understand, and it was only on 1/1/24 that the wound care orders were clarified and documented properly. However, the Gentamicin ointment was not available from the pharmacy to be administered on that day. Staff member D confirmed that the admitting physician was not the regular doctor for the resident's wounds and that the wound clinic could not be contacted over the weekend and holiday for order clarification. The deficiency was further highlighted during an interview with staff member D, who acknowledged that the admission orders did not include the complete wound treatment because the admitting physician was not familiar with the resident's wound care needs. The staff member also mentioned that the wound clinic, which had been treating the resident prior to admission, was closed for the weekend and holiday, making it impossible to obtain order clarification until 1/1/24. This delay in obtaining and clarifying wound care orders resulted in the resident not receiving the necessary wound treatments for several days, as documented in the medical records and treatment logs.
Inaccurate PBJ Data Submission for RN and Licensed Nurse Coverage
Penalty
Summary
The facility failed to accurately submit Payroll Based Journal (PBJ) data for Registered Nurse (RN) coverage, specifically eight consecutive hours per day for five days and 24-hour licensed nurse coverage for 25 days in Quarter One of Fiscal Year 2024. The review of the Quarter One report showed no RN hours for specific dates and failed to have licensed nursing coverage 24 hours per day for multiple dates. Employee timecards, however, indicated that RN hours and licensed nurse coverage were present on those dates, suggesting discrepancies in the data submitted to the PBJ system. During interviews, staff members revealed that the data submitted was based on a schedule provided by the Assistant Director of Nursing (ADON) to the business office at the beginning of each month. If changes were made to the schedule during the month, the business office did not receive an updated schedule. Staff member H admitted that she did not use employee timecards to enter data, leading to inaccuracies in the PBJ submissions. Staff member A confirmed that during a Quality Assurance and Performance Improvement (QAPI) meeting, it was identified that licensed staff hours were not correctly submitted to the PBJ, and the facility was working on developing a new process to report actual working hours for licensed staff.
Latest citations in Montana
A dependent resident admitted post-surgery with intact but vulnerable skin and MASD risk developed significant bilateral buttock MASD and a sacral pressure injury that progressed from deep tissue injury to Stage III and then to a large unstageable ulcer with odor and purulent drainage. Facility records showed incomplete and missing weekly skin/wound assessments during the period when the wound worsened, despite a care plan calling for skin evaluations, turning/repositioning, CNA skin inspections, and monitoring of nutrition. Staff interviews revealed they were frustrated by the resident’s anxiety and behaviors, reported the sacral wound as facility-acquired, acknowledged the resident became obtunded on an intense opioid regimen, and stated they were unaware of excessive fluid intake and could not explain why the worsening wound and infection were not recognized or reported before the resident required hospital transfer for a severe sacral decubitus ulcer with associated infection.
Surveyors found that kitchen staff failed to properly label and date multiple food items stored in the walk-in cooler, including slimy sliced tomatoes, ground meat, sliced ham, roast beef, cheese, and strawberries. Staff reported that they sometimes picked moldy strawberries out of shipments and that moldy dinner rolls had been served and then collected from residents. These practices did not follow the facility’s written policy requiring labeling, dating, and monitoring of refrigerated foods so they are used by their use-by date or discarded, placing all residents at risk for foodborne illness.
The facility failed to submit required investigation findings to the State Survey Agency (SSA) within 5 working days for multiple abuse and elopement incidents. In one case, a resident kicked another resident’s feet, and in another, one resident kicked another in the legs while both were in wheelchairs; in both situations, the facility did not provide timely or, in one case, any investigative findings to the SSA. The facility also reported two separate elopement events for a resident but did not submit final investigation reports for either incident. A staff member reported that another staff member, who was absent during the survey, was responsible for SSA reporting, and confirmed the expectation to report all investigation results within 5 working days per facility policy.
Two residents were involved in a resident-to-resident abuse incident in which one resident kicked another multiple times while both were in wheelchairs, and although staff separated them and documented the event, the facility did not complete or document a formal abuse investigation, did not ensure ongoing protection from further confrontations, and did not report investigative findings to the SSA. In addition, several residents experienced multiple elopements, with documentation that one resident followed others out back doors and another exited through doors into a hospital area, yet the facility’s investigation files lacked clear timelines, comprehensive staff interviews, identification of information sources, and root-cause analyses of exit-seeking behavior. Staff interviews confirmed that while nurses submitted occurrence reports and SSA notifications and discussed root causes informally, management did not consistently document thorough investigations or root-cause findings as required by facility policy.
The facility failed to provide adequate supervision and effective elopement-prevention interventions for several cognitively impaired, exit-seeking residents who were known elopement risks. Despite assessments, care plans, anti-wandering devices, and door alarms, residents repeatedly exited through front and back doors without timely staff redirection or alarm response, and some elopements were not properly documented in the EHR. One resident with dementia and short-term memory loss was not care planned for elopement until after multiple attempts, and another resident with severe cognitive impairment left through sliding doors unnoticed. A resident with an anti-elopement alarm on her wheelchair repeatedly triggered the door alarm throughout the day, yet staff did not effectively respond, allowing her to exit unsupervised and fall on stairs, sustaining minor injuries.
The facility failed to provide meaningful, resident-centered activities for multiple dementia residents in the memory care unit, resulting in individuals sitting idle in dining and common areas, staring at blank or inappropriate televisions, sleeping in chairs, or wandering hallways without engagement. Activity sessions were canceled or not implemented as scheduled, and when paper activities like word searches were offered, only a few residents participated while others received no assistance, including a resident who repeatedly requested glasses and another who did not speak English. Sitters did not help residents with activities, and an activity staff member spent time on a computer and left the unit for other duties. Staff interviews revealed that management directed the limitation of music and physical activities, that residents were often left in bed because it was easier for staff, that floor staff did not conduct activities in the absence of the activity staff, and that the posted activity calendar, which included exercise, trivia, book club, and weekend "Resident Choice Day," was frequently not followed despite a policy requiring meaningful activities tailored to dementia residents.
A hospice resident with metastatic cancer and behavioral symptoms received multiple sedating medications, including quetiapine, hydrocodone, morphine, lorazepam, olanzapine, and prednisone, without thorough assessment for unnecessary drugs, duplicate therapy, or adverse consequences. Despite documented behavioral issues, falls, cognitive decline, and moderate to severe pain scores, staff reported no concerns with the medication regimen. The resident became increasingly sedated, was found unconscious with minimal response to painful stimuli, and was sent to the hospital, where documentation linked the clinical picture to disease progression and medication effects, including opioid use and possible steroid-induced psychosis.
A resident with a documented history of opioid-induced constipation and prior fecal impaction was admitted from the hospital, where providers had noted difficulty balancing opioid use and constipation medications. On admission, facility documentation characterized the resident as having normal stool and rarely needing laxatives. Over the following weeks, bowel records showed multiple days without a bowel movement, yet the MAR reflected no scheduled or PRN constipation medications given. Nursing notes documented no constipation despite absent bowel sounds, while subsequent hospital imaging revealed an extensive rectal stool burden concerning for stercoral colitis. Staff interviews confirmed that the prolonged absence of bowel movements was not reported, the resident received no PRN bowel medications, and there was no specific bowel and bladder management policy.
Staff failed to follow hand hygiene practices while caring for a resident with weeping, hot lower legs who had been started on antibiotics for cellulitis. One staff member removed TED hose from the resident’s weeping left leg and then immediately assessed the right leg without changing gloves or performing hand hygiene. Another staff member, after applying TED hose to the weeping leg while gloved, continued to handle the resident’s food, pillow, and personal items and answered a cell phone by placing her gloved hand into her pocket, all without changing gloves or performing hand hygiene, contrary to the facility’s hand hygiene policy.
The facility failed to protect residents from abuse when one resident without capacity to consent was found in a common area with another resident’s hand inside her brief, and the subsequent investigation did not include interviewing or assessing other residents who might have been affected. In a separate event, a resident shook his spouse’s head and later sprayed water in her face with a spray bottle when she was tired at dinner, causing her agitation, while both continued to share a room and she spent most of her time and slept in common areas due to ongoing behaviors between them, as reflected in her care plan.
Failure to Prevent and Manage Pressure Ulcer Leading to Severe Sacral Wound
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate prevention and treatment of pressure ulcers and to complete and document required skin and wound assessments for a dependent resident. The resident was admitted from a hospital with red skin on the right elbow, a left neck surgical laminectomy site, and a left shin abrasion, and was totally dependent on staff for bed mobility, transfers, dressing, toileting, personal hygiene, and bathing, and had a Foley catheter. Within six days of admission, weekly wound documentation showed the resident had developed bilateral buttock moisture-associated skin damage (MASD) of significant size. The resident was then hospitalized for confusion and hyponatremia, and hospital wound care documented a deep tissue pressure injury to the sacrum that evolved into a Stage III pressure injury with yeast. When the resident returned to the facility, the facility’s readmit screener documented MASD to the buttocks and a yeast rash to the buttocks and groin, but no sacral pressure injury. Subsequent facility wound documentation showed that a few days after readmission, the resident had scattered ulcerations with MASD to the buttocks and a Stage III pressure ulcer to the right medial lower buttock, and that orders for treatment were requested from the physician. By the following week, the weekly wound observation tool documented that the Stage III bilateral buttock wounds had merged into one large unstageable pressure ulcer with odor and moderate purulent drainage, indicating potential infection. During this same period, there were no documented skin/wound assessments for the week leading up to the resident’s transfer back to the hospital, and a staff member later stated she did not know where the assessments were or why they were not done, and could not explain why no one reported that the wound was worsening. The care plan listed multiple skin integrity problems and interventions, including skin evaluations, routine turning and repositioning, CNA skin inspections with routine care, monitoring nutrition, and weekly nurse skin evaluations, but did not specify task frequency for some interventions. Interviews further described staff awareness and handling of the resident’s condition and behaviors. A family member reported that staff were frequently frustrated by the resident’s constant need for attention and anxiety, and that he repeatedly educated management about the resident’s high anxiety and hyperfocus, and did not understand how staff could report spending so much time with the resident yet not recognize how sick he was with infection. A staff member stated the sacral wound was facility-acquired, that the resident became obtunded related to opioids, and that she was unaware of the resident’s excessive water intake until after a hospital stay. Another staff member who completed a readmission history and physical found the resident febrile, with therapy unable to mobilize him due to pain, and described the resident as heavily sedated on an intense pain regimen that predated his stay. This staff member stated there were many opportunities for improvement in nursing assessments and that the facility could not handle the resident’s complex psychiatric and pain needs. Ultimately, the resident was transferred to the hospital with a large sacral decubitus wound with purulent tissue, surrounding cellulitis, and radiologic evidence of a severe sacral ulcer with erosion nearly to the coccyx and associated abscess and necrotizing soft tissue infection.
Improper Labeling, Dating, and Handling of Refrigerated Food Items
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage practices when, during an observation of the walk-in cooler, multiple food items were found undated or unlabeled, contrary to the facility’s Food Safety Requirements policy. Specifically, two zip-lock bags of slimy, sliced tomatoes were not dated; a gallon zip-lock bag of ground meat was not labeled with the food type or date; and separate gallon zip-lock bags of sliced ham, sliced roast beef, and sliced cheese were all undated. In addition, a cup of sliced strawberries had no date. Staff interviews revealed that kitchen staff had observed mold on strawberries upon delivery and would usually attempt to pick out the molded strawberries, and another staff member acknowledged awareness of ongoing dating issues with refrigerated foods. A further interview indicated that moldy dinner rolls had been served on one occasion, prompting staff to retrieve the rolls from residents after service. The facility’s written policy required labeling, dating, and monitoring refrigerated food, including leftovers, so it would be used by its use-by date or frozen/discarded, but these requirements were not followed, placing all residents at risk for foodborne illnesses. No specific residents or their medical histories were identified in the report; the deficiency was described as affecting all residents through improper food labeling, dating, and handling practices in the kitchen and walk-in cooler.
Failure to Submit Abuse and Elopement Investigation Findings Within Required Timeframe
Penalty
Summary
The facility failed to submit investigation findings related to alleged abuse and elopement incidents to the State Survey Agency (SSA) within the required 5 working days for multiple residents. For one incident dated 1/24/26, a resident left her room and kicked another resident’s feet; the facility’s investigative findings for this event were not submitted to the SSA until 2/4/26, which was 11 days after the incident was reported. For another incident dated 3/20/26, one resident kicked another resident in the legs while both were in wheelchairs, with no injuries reported and immediate separation of the residents; review of records showed no evidence that the facility ever submitted investigative findings for this incident to the SSA. Additionally, review of the SSA reporting site showed that the facility made initial reports of elopement for a resident on 7/18/25 and 2/1/26 but did not submit final investigation reports within the required 5 working days. There were no final reports for either elopement incident. During an interview, a staff member stated that another staff member, who was out of the facility during the survey week, was responsible for reporting and submitting investigative findings to the SSA for abuse allegations. The same staff member confirmed the expectation that findings of any abuse allegation be reported to the SSA within 5 working days and acknowledged they could not provide investigative findings for the 3/20/26 incident. The facility’s written policy, reviewed and dated 7/15/25, required that results of all investigations of alleged violations be reported within 5 working days of the incident.
Failure to Investigate Resident Abuse and Elopements or Identify Root Causes
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and manage an allegation of resident-to-resident abuse and multiple resident elopements. In one incident, a resident in a wheelchair kicked another resident multiple times in the lower legs while both were at the nurses’ station. Nursing documentation noted the kicking and that there were no injuries, and the immediate response was to separate the residents. However, review of the facility’s abuse investigations for the relevant period showed no completed investigation related to this reported allegation of resident-to-resident abuse, and there was no documentation of investigative findings or that these findings were reported to the State Survey Agency. The facility also failed to protect the involved residents from further potential abuse. Nursing notes for both residents documented that, two days after the kicking incident, one resident was observed continually attempting to follow, communicate with, agitate, and argue with the other resident, and staff had to separate them twice. Staff communicated to others to monitor their interactions, but the notes showed that the residents continued to have problematic contact, indicating that the facility did not prevent further potential abuse between them. During interview, a staff member stated that another staff person was responsible for investigating and reporting abuse allegations, but that person was unavailable and no documentation could be produced to verify that an investigation had been completed or that results were reported to the state agency, despite facility policy requiring thorough investigation, protection of residents during the investigation, and reporting of results. The deficiency also includes failures related to multiple elopements by several residents. For one resident, an elopement investigation documented that the resident exited the facility, but the investigation lacked signatures, identification of information sources, and clear involvement of the email sender included in the file. A state abuse reporting entry indicated that this resident left through back doors, possibly following a volunteer or staff taking other residents to Mass, and was brought back by a Med-Surg nurse, but there was no documented root-cause analysis or explanation of why the elopement occurred or what interventions were implemented to prevent recurrence. Another resident eloped through doors leading into the hospital; the reportable incident was submitted to the SSA, but there were no nurses’ notes on the date of the elopement describing the event, and a note the following day only stated that the resident attempted to elope twice, reflecting incomplete contemporaneous documentation. For this same resident, the facility’s investigation of the elopement included only limited staff interviews and did not include interviews with CNAs or activity staff to establish a full timeline of the resident’s movements or to identify the root cause. A subsequent elopement by this resident into the hospital was documented in a nursing note, and the investigation consisted of an undated handwritten note stating that people came into the unit looking for someone in the hospital, left to go to Med-Surg, and the resident followed them out the door, with the door alarm functioning and the resident returning to the unit. There was no documented timeline, no detailed interviews, and no analysis of the effectiveness of elopement-prevention interventions. A third resident had multiple documented elopements over several months, with investigation files that often contained only brief summaries, incomplete checklists, or limited supporting documents such as bounds reports or invoices for a wander guard system. Across these events, the facility did not consistently document root-cause analyses or assessments of the resident’s exit-seeking behavior, and the record notes that this failure to identify and document root causes led to a fall with injury for this resident. Interviews with staff confirmed that the facility’s practice did not align with its stated expectations. One staff member reported that a former staff person had previously conducted incident investigations but had left months earlier, and that the expectation for investigations was to determine the root cause of incidents and monitor residents to ensure interventions were implemented. Another staff member stated that after each elopement, the nurse would file a report to the SSA and update the care plan, after which management was supposed to conduct a full investigation. A further interview indicated that nurses entered occurrence reports and submitted SSA reports to track elopements and that staff discussed root causes but did not maintain documentation of those analyses. These statements, combined with the incomplete and inconsistent investigation records, demonstrate that the facility did not carry out or document thorough investigations, root-cause analyses, or protective measures as required by its own abuse investigation and reporting policy.
Failure to Prevent Elopements and Respond to Anti-Wandering Alarms
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and effective interventions to prevent elopements for multiple residents identified as at risk for wandering, despite existing assessments and care plans. Staff reported that residents at risk for elopement were identified by the MDS nurse on admission and quarterly, and that anti-wandering devices and door alarms were in place, particularly at the front door. However, staff also indicated that wander guard bracelets could be applied without formal assessment, and that information about elopement risk was communicated via paper “brain” sheets. The facility had a written SBAR and procedure for anti-wandering door alarms, including immediate resident location checks and following an elopement procedure, but the report shows these processes were not effectively implemented. One resident with a documented elopement risk and dementia was care planned to have an anti-wander device on her wheelchair and to be involved in activities and redirected when she attempted to exit. She eloped on at least two occasions: once when she went through the first set of doors and was found in a corridor by another resident, and another time when she exited through back doors, apparently following others going to Mass, with no alarms triggered. Her care plan documentation was inaccurate regarding the presence of a wander guard door in 2024, and there was no nursing documentation of the February elopement in her electronic health record. Another resident with severe cognitive impairment (BIMS score of 3) and an elopement risk care plan that included redirection, diversional activities, and ensuring door alarms were activated, was able to get out between the sliding front doors when someone was entering or exiting, and no one saw her leave, contrary to the care plan interventions. A further resident with dementia and short-term memory problems was identified as at risk for elopement, yet his elopement care plan and interventions were not initiated until after he had already eloped twice in one afternoon through different doors. He later eloped again, but the corresponding nursing note was not provided. Another resident, described as exit seeking and very independent with behavioral issues toward staff, had an anti-elopement alarm device on her wheelchair that sounded as she approached the door and had been near the door setting off the alarm throughout the day. Despite this, she was able to push open the main entrance sliding doors, exit, and then fall while attempting to walk down stairs, sustaining an abrasion and bruising and requiring hospital evaluation. Staff interviews indicated that interventions such as 1:1 monitoring, taking her outside, and diversional tasks were used, and that elopements were tracked via occurrence reports and state submissions, but the facility failed to identify the need for continuous one-on-one monitoring for this resident, failed to respond appropriately to the anti-elopement door alarm, and failed to prevent her unsupervised exit and subsequent fall. Activity staff also reported that, after a staffing reduction, there were no organized activities after 5 p.m., despite prior recognition that increased monitoring and activities during late afternoon hours were needed for an elopement-risk resident.
Failure to Provide Meaningful Activities for Dementia Residents in Memory Care Unit
Penalty
Summary
The deficiency involves the facility’s failure to provide meaningful, resident-centered activities to meet the needs of multiple residents with dementia in the memory care unit. Surveyors observed residents sitting in dining and common areas without any activities, including a resident with a BIMS score of 0 repeatedly scratching her arms while staring at a turned-off television, and another resident wandering the unit and running into walls. On another observation, the scheduled activities were canceled due to weather, and the activity staff member present was working on care plans on a computer while residents sat with newsletters in front of them, many staring at the floor or sleeping. Only some residents participated in the offered activities, while others, including residents with severely and moderately impaired memory, did not participate and were not engaged. During the same observation period, residents were given a word search activity, but only a few actively worked on it. Sitters, who were present to watch and redirect residents, sat at the tables and did not attempt to assist residents with the activity. One resident repeatedly stated she needed her glasses to see the paper, but no staff obtained her glasses. A resident who did not speak English sat staring down the hall without engagement, and another resident with severe cognitive impairment wandered the hall. The activity staff member stated she had other duties in another unit and left, and later that evening, surveyors observed one resident sleeping in a recliner and another staring at a wall while cartoons played on the television. Interviews with staff revealed that activities in the memory care unit were limited and often not implemented as scheduled. The activity staff member reported she was instructed by management to avoid music and physical activities because staff believed these would cause residents to become agitated, and that she was told to limit activities to calming options only. She also stated that residents were often left in bed and not taken to activities because it was easier for staff, and that floor staff did not provide activities when she was not present, preferring residents to sit quietly. Other staff confirmed that activities usually did not occur in the memory care unit, that activities observed during the survey were a show for surveyors, and that the activity calendar was not followed. The memory care activity calendar showed “Resident Choice Day” on all weekends and listed trivia, exercise/stretching, and book club on weekdays, while the facility’s activities policy required activities to enhance well-being, physical activity, cognition, and to provide meaningful activities for residents with dementia.
Failure to Assess Hospice Resident’s Polypharmacy and Sedation Risk
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s drug regimen was free from unnecessary medications and thoroughly assessed for sedation, duplicate therapy, and adverse consequences. A hospice resident with metastatic cancer, delirium, psychosis, and impulsive, intermittently aggressive behavior was receiving multiple medications including antipsychotics, opioids, benzodiazepines, and a steroid. Hospice staff discontinued some medications and added morphine and lorazepam, while the resident also continued on quetiapine, hydrocodone, prednisone, and later received a one-time dose of olanzapine. Facility staff A and B reported that they had no concerns with the resident’s medications despite the combination of psychotropic and sedating drugs. The resident had been ambulatory on arrival to the facility but became weaker with multiple falls, nonsensical and incoherent speech, and combative and unsafe behavior. One-to-one supervision was initiated due to impulsivity and aggression, and staff questioned whether pain contributed to the aggressive behavior. The resident’s pain scores documented on the Medication Administration Record over three days showed moderate to severe pain levels (5/10, 3/10, and 7/10), while the resident continued to receive multiple sedating medications, including quetiapine every eight hours, hydrocodone three times daily, lorazepam as needed every four hours, morphine as needed every four hours, and prednisone daily. On the day before transfer to the hospital, the resident received olanzapine, prednisone, hydrocodone, two doses of lorazepam, and morphine; on the day of transfer, the resident received lorazepam, morphine, and prednisone. When a family member arrived at the facility, they found the resident unconscious with minimal response to painful stimuli and appearing sedated, and they requested transfer to the hospital. The family reported the resident had been more sedated at the facility lately, and the emergency room provider reportedly told the family the resident had an overdose of medications. Hospital documentation noted altered mental status, hypoxia, and that the resident’s dementia and chronic encephalopathy may have been exacerbated by disease progression and opioid use, possible steroid-induced psychosis, and electrolyte imbalance. The facility did not identify or address the resident’s medication regimen as a contributing factor to sedation or assess for duplicate therapy and adverse consequences prior to the resident’s transfer.
Failure to Monitor and Treat Constipation in Resident With Opioid-Induced Constipation History
Penalty
Summary
The facility failed to monitor and manage constipation for a resident with a known history of opioid-induced constipation and prior use of constipation medications. Hospital records showed the resident had been admitted with a 9.6 cm fecal impaction and that the hospital physician documented the resident could go up to five days without a bowel movement, likely due to opioid use, and was working on balancing opioid-induced constipation with constipation medications. Upon admission to the facility, the Admit/Readmit Screener documented that the resident had normal formed stool and rarely or never depended on laxatives, despite this history. Facility bowel documentation later showed gaps in bowel movements, including no bowel movement for several days. Review of the Medication Administration Record for March and April showed the resident did not receive any scheduled or PRN constipation medications during the stay. Bowel documentation indicated no bowel movement from 3/29 to 4/3, followed by diarrhea on 4/4 and a putty-like stool on 4/5. A nursing progress note on 4/6 documented a flat, non-tender abdomen with no bowel sounds and no constipation, while hospital records from the same date, after readmission, showed an extensive stool burden distending the rectum to 8.8 cm with findings concerning for stercoral colitis. Staff interviews revealed that no one reported the resident had gone six days without a bowel movement, the resident had gone without any PRN bowel medications, and the facility did not have a policy specific to bowel and bladder management.
Failure to Perform Hand Hygiene During Wound and Skin Care
Penalty
Summary
Facility staff failed to ensure proper hand hygiene during care of a resident with suspected infected lower extremities. During an observation, two staff members entered the room of a resident who had reported weeping and hot lower legs. One staff member removed the TED hose from the resident’s left leg, noted that the leg was hot to the touch and weeping edema fluid, then moved directly to the right leg, removed the TED hose, and assessed that leg without changing gloves or performing hand hygiene between contact with the weeping left leg and the intact right leg. This same staff member later stated she believed she had completed all hand hygiene opportunities but realized, when questioned, that she had moved from one leg to the other without performing hand hygiene. The resident had been started on Cipro for cellulitis on the morning of the observation. A second staff member returned to the room with new TED hose and socks, donned gloves, and assisted with applying the TED hose. This staff member applied TED hose to the resident’s left leg, observed weeping fluid from the skin, and then proceeded to clean up the room while still wearing the same contaminated gloves. While gloved, she touched the resident’s food on the bedside table, handled the resident’s pillow and placed it on the chair where the resident was sitting, and put her gloved hand into her clothing pocket to turn off her ringing cell phone. She did not perform hand hygiene or change gloves after contact with bodily fluids and before touching other items in the room. After leaving the room, she stated she had not thought about performing hand hygiene after finishing application of the TED hose. The facility’s hand hygiene policy required hand hygiene after handling contaminated objects, when moving from a contaminated site to a clean body site during resident care, and after handling items potentially contaminated with blood or bodily fluids.
Failure to Protect Residents From Sexual and Physical Abuse by Other Residents
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from abuse, including sexual and physical abuse, by other residents. In one incident, a resident without capacity to consent was found in a common area with another resident’s hand inside her brief up to the wrist. Staff immediately separated the residents, and the incident was reported to the State Survey Agency; however, the facility’s investigation did not include interviewing or assessing other residents who might have been present or potentially affected by similar sexual abuse incidents. A staff member also reported that the incident was initially reported under the wrong license type because they were unaware the facility held both an adult day care and a skilled nursing facility license. In a separate incident, a resident became upset with his spouse, also a resident, during dinner and shook her head to wake her, then later sprayed water in her face with a spray bottle after staff had intervened and moved her to the nurses’ station. The spouse became agitated by these actions. Observations showed that the couple continued to share a room, with both residents’ nameplates and belongings present. Staff interviews indicated that the spouse who was the target of the behavior was usually kept out of the room and spent most of her time and slept in common areas or by the nurses’ station due to ongoing behaviors between the two. The care plan for the spouse reflected that she was not to be in the room when her husband was present unless both wanted to be there, and staff were to intervene if yelling occurred, based on the prior incident of head shaking and use of the spray bottle.
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