Benefis Senior Services - Westview
Inspection history, citations, penalties and survey trends for this long-term care facility in Great Falls, Montana.
- Location
- 500 15th Ave S, Great Falls, Montana 59405
- CMS Provider Number
- 275158
- Inspections on file
- 8
- Latest survey
- May 28, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Benefis Senior Services - Westview during CMS and state inspections, most recent first.
A resident was subjected to mental abuse when staff restricted her right to private in-room visitations, requiring all visits with certain individuals to occur only in common areas for staff convenience. This restriction was imposed without documented safety concerns, contradicted the resident's care plan preferences for socialization, and led to the resident experiencing ongoing feelings of isolation, frustration, and being watched.
A resident with a history of skin breakdown developed a worsening Stage III pressure ulcer due to inconsistent wound assessment, measurement, and dressing changes, with staff failing to follow physician orders and facility policy for documentation. Another resident with an indwelling catheter developed a wound on the foreskin after staff failed to provide consistent and proper perineal care, and the wound went undocumented and unrecognized by staff until observed during the survey.
Two residents did not have comprehensive, person-centered care plans in place to address their specific needs. One resident's care plan lacked critical details for dialysis management, such as monitoring protocols and emergency contacts. Another resident with cognitive impairment and a history of elopement did not have interventions or risk identification documented in the care plan, despite repeated incidents and discussions about moving to a secure unit.
A resident with severe cognitive impairment repeatedly accessed unmonitored elevators and was found on other floors or searching for exits, yet was not assessed as at risk for elopement and did not have interventions reflected in the care plan. Staff were unclear on elopement definitions, did not use the wander guard system, and failed to move the resident to a secure unit despite available beds, resulting in ongoing elopement hazards.
Insufficient nursing staff resulted in delayed wound care, inconsistent completion of ADLs, and prolonged call light response times. A resident's pressure ulcer worsened due to missed dressing changes and lack of wound monitoring, while other residents experienced delays in hygiene care and repositioning. Staff and residents reported frequent low staffing, with only one nurse and two CNAs at times for 34 rooms, directly impacting the quality and timeliness of care.
A resident was not allowed to have visitors in her room and was only permitted to meet with friends in the common area, as directed by staff. Staff interviews revealed inconsistent understanding of visitation rules, and the facility only had a hospital-wide policy, not one specific to LTC. Staff confirmed there was no developed or communicated visitation policy for long-term care services, affecting all residents and their visitors.
Two residents experienced a lack of privacy: one was not permitted to have private visits in her room and was required to meet visitors in a non-private common area, while another did not have a door or curtain on her bathroom, leaving her feeling exposed. Staff were either unaware of or responsible for these privacy lapses, which were contrary to the facility's stated policies on resident rights.
A resident was found with a wheelchair seat belt restraint that they could not remove independently, without a current physician order, documented medical justification, or inclusion in the care plan. Staff indicated the restraint was used for fall prevention, but facility policy requiring assessment, documentation, and care planning for restraints was not followed.
A nurse pre-poured and scanned medications for several residents, documenting them as administered in the MAR before actually giving them. Medications were then administered at later times than recorded, resulting in inaccurate documentation for at least three residents. The nurse admitted this practice occurred, especially when short-staffed or running behind, and acknowledged it was improper.
Two residents did not consistently receive assistance with basic ADLs, such as hair and oral care, and were sometimes left in their rooms without encouragement to participate in meals or social activities. Staff interviews and observations indicated a reliance on family members to provide these cares, rather than ensuring staff completed them.
Several residents with limited mobility were not regularly repositioned by staff, resulting in prolonged periods in the same position without the use of positioning aids. Residents reported discomfort, soreness, and concerns about skin breakdown, while staff interviews indicated that the restorative aide was overextended and CNAs were not consistently providing necessary turning and mobility assistance.
A resident receiving hemodialysis did not have a physician order for dialysis documented upon admission, with the order only created months later. The resident also reported not receiving adequate protein with a meal and expressed dissatisfaction with the available options. Staff confirmed the resident should have received double protein servings and that alternatives were available, but these were not provided.
Surveyors identified that staff failed to properly administer and document medications for three residents, including not verifying or recording vital signs before giving digoxin, not providing a prescribed topical cream as documented, and not administering an inhaler despite documentation stating otherwise. These actions resulted in a medication error rate of nine percent.
A resident with significant hand deformities and discomfort from a previous bone break experienced a three-month delay in receiving an orthopedic consult due to the facility's failure to follow up on a referral. Although the referral was ordered, it was not completed because the orthopedic provider contacted the resident's personal cell phone instead of the unit, and nursing staff did not ensure the follow-up was finalized.
The facility failed to serve food at safe and appetizing temperatures, affecting several residents. Observations revealed that food was often cold, and staff relied on microwaving without proper temperature checks, contrary to facility policy. Residents reported dissatisfaction with meal temperatures, and staff admitted to reheating food primarily due to surveyor presence.
The facility failed to honor resident preferences for shower frequency, with three residents reporting dissatisfaction with the current schedule. They expressed a desire for more frequent showers, but the facility's documentation did not reflect any refusals or unavailability. Staff interviews indicated that showers were often postponed due to other tasks, but these instances were not documented, and the facility lacked a specific policy addressing shower frequency and preferences.
The facility failed to provide scheduled bathing assistance to three residents, resulting in extended periods without showers. Despite being scheduled for regular showers, these residents experienced significant gaps between bathing sessions, with no documentation of refusals or unavailability. Interviews confirmed infrequent showers, indicating a failure to adhere to the facility's policy on personal hygiene assistance.
A resident with significant health issues, including skin concerns and mobility limitations, did not have a comprehensive care plan addressing all their needs. The care plan lacked documentation for essential ADLs and did not reflect the resident's nutritional needs for healing. Staff interviews highlighted challenges in completing scheduled care tasks, such as showers, due to workload and resident availability.
Resident Subjected to Mental Abuse Through Restriction of Visitation Rights
Penalty
Summary
The facility failed to ensure a resident was free from mental abuse by depriving her of her rights to private visitations and by isolating her from social interactions for staff convenience. The resident was not allowed to have visitors in her room and was repeatedly told by staff to move her visits to the common area. This restriction was imposed despite the resident expressing that socialization was very important to her and that the limitation caused her to feel dull, bored, frustrated, and like a prisoner. The restriction had been in place for several months, and the resident agreed to it only to keep peace with the staff, not because she felt it was appropriate. Multiple staff interviews confirmed that the directive to limit the resident's in-room visitors originated from a specific staff member, who cited concerns about the resident discussing facility issues with others and encouraging complaints. There were no documented safety concerns or incidents that justified the restriction, and staff acknowledged that the resident's visitors, including a long-time friend and another resident's family member, were not involved in any inappropriate behavior. The facility did not provide the resident with written documentation or rationale for the visitation limitation, and the decision was not based on any documented behavioral or safety issues. The resident's care plan indicated a preference for socialization and maintaining her current level of social interaction, with a goal of avoiding complaints of isolation. However, the imposed visitation restrictions directly contradicted these care plan goals and the facility's own policies, which guarantee residents the right to private visits and to voice concerns without fear of punishment. The actions taken by staff resulted in the resident experiencing ongoing negative psychosocial effects, as evidenced by her own statements and corroborated by interviews with friends and staff.
Failure to Consistently Assess, Document, and Provide Wound and Perineal Care
Penalty
Summary
The facility failed to consistently assess, measure, and monitor a resident's pressure ulcer, and did not ensure wound dressings were provided as ordered by the physician. One resident with a history of Addison's disease and susceptibility to skin breakdown developed a Stage III pressure ulcer on the back of her right upper thigh after readmission from the hospital. The resident reported that staff did not listen to her instructions on wound dressing application, resulting in dressings that frequently rolled up and came off. She also stated that dressing changes were not performed consistently, and wound care was not always provided as scheduled. Observations confirmed the presence of a worsening wound, and record reviews showed a lack of consistent wound assessment, measurement, and documentation between physician visits, despite facility policy requiring regular monitoring and documentation. Staff interviews revealed that wound care and assessments were primarily performed by a wound care nurse who visited weekly, but measurements were not always taken at each dressing change, and sometimes the nurse did not return to complete wound care if the resident was unavailable. Other nursing staff were expected to perform dressing changes as ordered, but documentation was inconsistent or missing for multiple dates. The resident's wound progressed from improving to worsening over a period of several weeks, as documented by the Wound Clinic physician, with a significant increase in wound size. Facility records and task histories confirmed that dressing changes and wound assessments were not completed or documented as required by physician orders and facility policy. Additionally, the facility failed to ensure proper perineal care for another resident with an indwelling catheter, resulting in the development of a wound on the foreskin. The resident reported inconsistent perineal care and that staff often failed to properly clean the area, especially under the foreskin. Staff were unaware of the wound until it was observed during the survey, and there was no prior documentation or notification regarding the wound. The lack of proper perineal care and failure to identify and document the wound contributed to the resident's condition.
Failure to Develop and Implement Comprehensive, Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, resulting in unmet care needs. For one resident with multiple diagnoses including congestive heart failure, diabetes, and pulmonary fibrosis, the care plan did not include essential details related to dialysis care. Missing elements included the dialysis center's contact information, specifics on monitoring pre- and post-dialysis vitals, transportation arrangements, the type and location of dialysis, which arm to use for blood pressure, emergency contacts for dialysis-related issues, and monitoring for complications such as infection or hypotension at the access site. Another resident with cognitive impairment, ataxia, and a history of traumatic brain injury experienced repeated elopement incidents. The care plan did not identify the resident's elopement risk or outline interventions to prevent further incidents, nor did it include person-centered activities or diversions tailored to the resident's interests or dementia progression. Despite multiple documented elopements and discussions about transferring the resident to a secure unit, the care plan was not updated to reflect these risks or interventions.
Failure to Identify and Address Elopement Risk for Cognitively Impaired Resident
Penalty
Summary
The facility failed to timely identify and address elopement risks for a resident with severe cognitive impairment. The resident, who had a BIMS score of 7 indicating severe cognitive deficits, was not assessed as being at risk for elopement in the most current available assessment, and no updated elopement assessment was provided during the survey. Despite repeated incidents where the resident accessed elevators and was found on other floors or searching for exits, the care plan did not reflect the resident's wandering or elopement risk, nor did it provide staff with guidance on managing these behaviors. Multiple nursing notes documented the resident's repeated attempts to use the elevator and leave the unit, including instances where the resident was found on different floors and continued to seek exits for extended periods. Staff attempted to redirect the resident without success, and discussions occurred about moving the resident to a secure unit. However, there was no documented follow-up or implementation of this intervention, even though secure unit beds were available in the facility. Staff interviews revealed a lack of awareness and understanding regarding the classification of elopement events, with some staff considering the incidents as AWOL rather than elopement, despite the resident's cognitive impairment. Additionally, the facility's wander guard system was not utilized for this resident, and staff were unsure how it functioned on the unit. The facility had unmonitored elevators and exits, further contributing to the ongoing elopement hazard for the resident.
Insufficient Staffing Leads to Delayed Care and Unmet Resident Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, resulting in several care deficiencies. One resident with a pressure ulcer on her right upper leg reported that her dressing was not changed consistently, particularly during the day when staff stated they did not have time. Medical record review confirmed that the wound was not assessed, measured, or monitored for nearly a month, and a Wound Clinic note documented that the pressure injury worsened during this period. Staff interviews corroborated that dressing changes were not completed as ordered and that wound care documentation was lacking. Other residents experienced unmet needs related to activities of daily living (ADLs) and long call light response times. One resident was often left in her room in the dark during breakfast, missing opportunities for socialization and encouragement to eat. Another resident reported waiting an hour and a half to be changed and stated that basic hygiene tasks such as face washing and hair brushing were inconsistently performed. Observations confirmed that at times, no CNAs were present on the floor, and staff reported that the unit was frequently staffed with only one nurse and two CNAs for 34 rooms, with some residents requiring two-person assistance for transfers. Multiple residents and staff expressed concerns about low staffing levels, with reports of call lights going unanswered for extended periods and residents feeling reluctant to request assistance. Staff described being floated to other buildings and feeling short-staffed more than half the time. The call light system was also reported to be down, preventing the facility from providing call light response data. These staffing shortages directly contributed to delays in care, incomplete ADLs, and inadequate repositioning for residents at risk of skin breakdown.
Failure to Develop and Communicate LTC-Specific Visitation Policy
Penalty
Summary
The facility failed to develop, implement, and inform residents of a specific visitation policy and procedure for long-term care services. One resident reported being restricted from having visitors in her room and was only allowed to meet with friends in the common area, as directed by staff. The resident stated she complied with this arrangement to avoid conflict with staff. Multiple staff interviews revealed inconsistent understanding and application of visitation policies, with some staff indicating that overnight visits required prior approval and others referencing a general hospital policy rather than one tailored to long-term care. Upon request, the facility provided a visitation policy that was specific to the hospital system and not applicable to the long-term care setting. Staff confirmed that there was no developed policy or procedure for visitation related to Senior Services or long-term care. This lack of a specific and communicated visitation policy had the potential to affect all residents and their visitors, as it resulted in inconsistent practices and lack of clarity regarding residents' visitation rights.
Failure to Ensure Resident Privacy During Visits and Bathroom Use
Penalty
Summary
The facility failed to ensure resident privacy in two separate instances. One resident was not allowed to have visitors in her room and was instructed by staff to meet with visitors only in the common area, which did not provide privacy for conversations. Multiple staff interviews confirmed that this restriction was imposed by a staff member, and the facility's own policy and resident rights documentation state that residents are entitled to private visits and to have visitors at any time. In another case, a resident's bathroom lacked a door or privacy curtain, leaving the bathroom open to the main living space. The resident expressed discomfort and a sense of exposure, particularly when showering. Staff were unaware of the resident's concerns, despite facility policy stating that residents are entitled to proper privacy, property, and living arrangements.
Failure to Document and Justify Use of Physical Restraint
Penalty
Summary
A resident was observed sitting in a wheelchair near the nurse's station with a loose-fitting seat belt that the resident was unable to remove independently when prompted. The resident's records showed that the last assessment for the use of restraints or alarms was completed nearly three years prior, and this evaluation did not specify any medical condition or symptom being treated by the use of the seat belt. There was no documentation in the resident's electronic health record of ongoing re-evaluation for the need for a physical restraint, and the most recent care plan did not mention the use of a seat belt. During staff interview, it was stated that the seat belt was used to prevent falls and that care plans are typically updated after such events, but the staff member was unaware that the seat belt was not included in the current care plan. Additionally, there was no physician order for the use of the wheelchair seat belt, as required by the facility's own policy. The policy mandates a physician's order with documented rationale, appropriate nursing assessment, and care plan initiation for any restraint, as well as quarterly reassessment for restraint reduction, none of which were present in this case.
Inaccurate Medication Administration Times Documented in MARs
Penalty
Summary
The facility failed to ensure that pre-poured medications were administered in a timely manner and that medication administration records (MARs) accurately reflected the actual times medications were given. During observation and interviews, a staff member was found to have pre-poured medications for multiple residents and stored them in a locked medication cart drawer. The staff member scanned the medications into the MAR as if they had been administered at that time, even though the medications were not actually given until later. The staff member admitted to sometimes changing the administration time in the MAR to match the actual time, but on the day of observation, did not do so due to being late and running behind. The staff member also indicated that this practice occurred more frequently when the facility was short-staffed and acknowledged that this method was incorrect. Specific instances were observed where residents received their medications at times that did not match the times documented in their MARs. For example, one resident received medications at 8:14 a.m., but the MAR showed administration at 7:32 a.m.; another received medications at 8:19 a.m., with the MAR indicating 7:38 a.m.; and a third resident received medications at 8:28 a.m., while the MAR documented 8:03 a.m. These discrepancies resulted in inaccurate documentation of medication administration times for at least three residents. Staff interviews confirmed that this practice was unacceptable and did not meet professional standards of quality.
Failure to Provide Consistent ADL Support and Reliance on Family for Care
Penalty
Summary
Staff failed to ensure that two residents received assistance with basic activities of daily living (ADLs), such as hair and oral care, as well as support to get out of bed and participate in meals and social activities. One resident, who had a history of stroke and was unable to brush the right side of her hair, reported that her face was only sometimes washed in the morning and her hair was only partially brushed. Observations confirmed that her hair and teeth were not consistently cared for, and a staff member noted that they often provided these cares only when a family member was present, raising concerns about what would happen if the family member did not visit daily. Another resident was frequently left in her room in the dark during breakfast, not encouraged to get out of bed, eat, or socialize with others. Observations showed that her hair remained in frizzy braids that appeared to have been slept in throughout the morning. Staff interviews revealed a pattern of relying on family members to complete basic ADLs, rather than ensuring staff provided these essential cares.
Failure to Reposition Residents to Prevent Skin Breakdown
Penalty
Summary
The facility failed to ensure that residents with limited mobility were regularly repositioned to prevent skin breakdown. Multiple residents reported that staff only repositioned them upon request, and observations confirmed that residents remained in the same position for extended periods without the use of positioning aids such as pillows or wedges. One resident noted that staff applied cream to her buttock area, which was observed to be slightly pink and blanchable, but she was not informed about the condition of her skin. Another resident reported soreness from prolonged sitting and was not observed to be repositioned during the survey period. Documentation showed that one resident was not turned at all on several days. Staff interviews revealed that the restorative aide responsible for mobility and repositioning services was covering approximately 70 residents across three buildings, and that CNAs could assist with turning and repositioning, but nurses were described as too busy to help. Residents expressed concerns about inadequate cleaning and the risk of skin breakdown, with some reporting recurrent UTIs and discomfort from prolonged immobility. The electronic health records did not consistently reflect the residents' actual skin conditions or repositioning needs.
Failure to Ensure Physician Orders and Appropriate Nutrition for Dialysis Patient
Penalty
Summary
The facility failed to provide safe and appropriate dialysis care and services for a resident requiring hemodialysis. The resident, who regularly attended dialysis at an off-site center, did not have a physician order for dialysis treatment documented upon admission, with the order only being created several months later. Additionally, the resident reported not receiving adequate protein with a supper meal, expressing dissatisfaction with the lack of meat options and stating he was tired of chicken. Staff confirmed that the resident should have been receiving double servings of protein and that alternative options were available if the resident did not want chicken. Observations confirmed the resident was not present to eat the meal provided, which included green beans, a bun, chicken noodle soup, and pumpkin pie, and did not include a protein alternative as per the resident's dietary needs and preferences.
Medication Administration Errors and Documentation Failures
Penalty
Summary
The facility failed to ensure that prescribed medications were administered as ordered for three residents, resulting in a medication error rate of nine percent. For one resident prescribed digoxin, staff administered the medication after stating they had taken the resident's pulse earlier in the morning, but there was no documentation of any vital signs, including pulse, on the day of administration. The physician's order for digoxin specified to hold the medication if the pulse was less than 50, but this parameter was not verified or documented at the time of administration. Additionally, another resident did not receive their prescribed Lotrimin cream as documented on the Medication Administration Record (MAR), despite the staff member stating they would return to administer non-pill medications after distributing oral medications. The resident, who was cognitively intact, reported not receiving the cream and indicated this was a recurring issue. A third resident, also cognitively intact, reported not receiving their inhaler, although the MAR indicated it had been given. These failures were observed and confirmed through interviews, record reviews, and direct resident statements.
Delay in Orthopedic Referral Follow-Up for Resident with Hand Deformities
Penalty
Summary
A deficiency occurred when the facility failed to ensure timely follow-up on a referral for an orthopedic consult for a resident with significant deformities and discomfort in her right hand, specifically the index and ring fingers, resulting from an old bone break. The resident had requested to see an orthopedic doctor, and a referral to a hand surgeon was documented in the physician's progress notes. However, a review of the electronic medical record did not show any result or evidence of the referral being completed. Staff confirmed that although the order was sent, the orthopedic provider had contacted the resident's personal cell phone instead of the unit's line, and nursing did not complete the necessary follow-up, resulting in a delay of three months before the resident was set up to be seen.
Failure to Serve Food at Safe Temperatures
Penalty
Summary
The facility failed to provide residents with food at a safe and appetizing temperature, affecting four of the sixteen sampled residents. Multiple residents reported that their meals were consistently served cold, and observations confirmed that food items were not at the appropriate temperature when served. For instance, a resident received a peanut butter and jelly sandwich with wet and soggy bread, and another resident's sausage was served at 84.8 degrees Fahrenheit before reheating. Staff members were observed microwaving food without checking temperatures before or after reheating, relying on visual cues like steam to determine if the food was adequately heated. The facility's policy required that food temperatures be checked upon arrival from the main kitchen and reheated in an oven if below 140 degrees Fahrenheit. However, staff members did not adhere to this policy, as they did not consistently check temperatures or use the oven for reheating. Instead, they used microwaves, which was not in line with the facility's procedures. Staff members admitted to reheating food in the microwave primarily because surveyors were present, indicating a lack of consistent practice in maintaining food safety standards. The facility's failure to follow its policy and ensure food was served at safe temperatures led to the deficiency.
Failure to Honor Resident Preferences for Shower Frequency
Penalty
Summary
The facility failed to honor and facilitate resident self-determination by not providing residents with choices regarding the timing and frequency of showers. Three residents expressed dissatisfaction with the current shower schedule, which was not aligned with their preferences. Resident #104 reported being allowed only one shower per week, with significant gaps between showers, and expressed a desire for more frequent showers. Resident #114 also stated she received only one shower a week and wished for more, while resident #126 indicated she was scheduled for one shower a week but often went longer periods without assistance, despite needing help. The facility's documentation did not reflect any refusals or unavailability of the residents for showers, suggesting a lack of proper record-keeping. Staff interviews revealed that showers were often postponed due to other tasks or resident unavailability, but these instances were not documented. Additionally, the facility lacked a specific policy addressing shower frequency and resident preferences, contributing to the inconsistency in meeting residents' needs and preferences for personal hygiene.
Failure to Provide Scheduled Bathing Assistance
Penalty
Summary
The facility failed to provide adequate assistance with bathing for three residents, resulting in extended periods without showers. Resident #119 was scheduled for showers twice a week, but records showed gaps of 11 and 13 days between showers. Similarly, resident #121, who was scheduled for weekly showers, experienced gaps of 10, 11, and 12 days. Resident #127, also scheduled for weekly showers, had gaps of 14, 8, and 10 days between showers. Interviews with residents #121 and #127 confirmed infrequent showers, and there was no documentation indicating that any of the residents refused or were unavailable for their scheduled showers. The facility's policy on activities of daily living (ADLs) requires that assistance with personal hygiene and bathing be provided as directed in the care plan and documented in the medical record. However, the facility did not adhere to this policy, as evidenced by the lack of documentation for refusals or unavailability and the extended periods between showers for the affected residents. This deficiency was identified through interviews and record reviews, highlighting a failure to meet the residents' needs for personal hygiene assistance.
Inadequate Care Plan for Resident with Multiple Health Concerns
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident with multiple health concerns, including skin issues, nutrition, activities of daily living (ADLs), mobility, and urinary concerns. The resident was admitted with diagnoses such as rectal ulceration, a second-degree burn on the abdomen, incomplete paraplegia, and a suprapubic catheter. Despite these significant health issues, the care plan initiated for the resident only addressed dental care and nutrition, lacking documentation for assistance with ADLs like bathing, dressing, transferring, mobility, catheter care, or wound care. Observations and interviews revealed that the resident relied on a wheelchair for mobility and required staff assistance for transfers and hygiene. Staff interviews indicated challenges in completing scheduled showers due to workload and resident availability, with no documentation of refusals or missed showers. Additionally, although the resident had skin concerns and required extra nutrition for healing, this was not reflected in the care plan. The facility's policy required a comprehensive interdisciplinary care plan within 21 days of admission, but this was not adequately developed for the resident in question.
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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