Billings Rehabilitation And Nursing Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Billings, Montana.
- Location
- 600 S 27th St, Billings, Montana 59101
- CMS Provider Number
- 275120
- Inspections on file
- 35
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 45
Citation history
Health deficiencies cited at Billings Rehabilitation And Nursing Llc during CMS and state inspections, most recent first.
The facility failed to timely report an allegation of sexual abuse and to submit investigation findings for multiple abuse-related events to the State Survey Agency. A resident with a history of inappropriate contact with female residents was observed placing his hand on another resident's thigh while assisting with feeding; a staff member intervened and reported this to a nurse, who documented the behavior but did not report it as required. In separate incidents, a verbal altercation between two residents and a resident's allegation of verbal abuse by a staff member were reported as events, but the required investigation findings were submitted to the state one day past the regulatory deadline, despite internal alerts and established abuse-reporting policies.
The facility failed to investigate an allegation of inappropriate, nonconsensual resident-to-resident contact. A behavior note documented that a resident had repeatedly entered female residents’ rooms and rubbed their legs, and specifically referenced an incident involving two residents. This event was not reported to the State Survey Agency and was not investigated, despite a facility policy requiring immediate investigation of suspected abuse, neglect, or exploitation, including identifying responsible staff, interviewing all involved parties and witnesses, and thoroughly documenting the findings.
A resident sustained first- and second-degree burns to the abdomen, groin, and hip, and nursing staff did not consistently assess, treat, and document the wounds according to professional standards. Initial notes described the burns and provider orders for daily dressings, but subsequent entries were sporadic, lacked detailed wound assessments (including measurements, classification, edges, odor, pain, and infection status), and did not address all affected areas. The wound nurse left unexpectedly, and the replacement nurse was unaware of the wound until it had already resolved. The MAR showed multiple days where ordered daily dressing changes to the hip burn were not documented as completed, contrary to the facility’s wound management policy and ANA documentation principles.
A resident with a below-the-knee amputation had their stump secured to a wheelchair footrest using a compression wrap that could not be removed independently. Staff used the wrap without a physician's order, assessment, or documentation, and there was no monitoring or evaluation of the restraint or the resident's skin. Facility policy requiring assessment and authorization for restraints was not followed.
A resident with a wound and intermittent confusion was admitted and required varying levels of assistance with activities of daily living, but no baseline care plan was completed within 48 hours as required. Staff confirmed the care plan was still blank at the time of review, despite facility policy mandating timely completion to address immediate care needs.
A resident who was missing teeth and relied on dentures did not have a care plan that accurately reflected their dental status or specific oral care needs. Staff provided inconsistent oral and denture care, and family members reported having to clean the resident's dentures themselves due to staff neglect. The facility's care plan lacked essential details, and documentation of oral care was insufficient.
A resident with a left below-knee amputation refused to wear a prescribed brace, leading staff to use a compression wrap to secure the stump to the wheelchair leg rest. The care plan was not updated to reflect the resident's refusal, the use of the compression wrap as a restraint, or related risks, despite facility policy requiring such revisions.
Multiple residents reported ongoing delays in meal service, with meals often served hours late and complaints not resulting in timely resolution. Staff confirmed dietary short-staffing contributed to the delays, and grievance documentation showed repeated concerns without evidence of prompt or effective response.
The facility did not provide timely notification to the State Long-Term Care Ombudsman regarding the transfer and discharge of three residents. Interviews and record reviews showed that required notifications were not sent, and staff responsible for this process was unaware of the requirement, resulting in missing documentation in the affected residents' charts.
Several residents experienced repeated delays in meal service, with some receiving meals hours late or having to rush to attend activities or take medications. Staff confirmed that ongoing staffing shortages contributed to the late meal delivery, and all available personnel were observed assisting with meal service in the dining room.
A resident with a suprapubic catheter experienced ongoing skin breakdown and frequent bladder infections due to inconsistent catheter care, including improper cleaning methods and failure to secure the catheter. Staff interviews revealed confusion about care procedures and lack of communication regarding the resident's condition, despite facility policies outlining appropriate catheter care and reporting requirements.
A resident with end-stage COPD experienced a severe weight loss over two months, but the facility did not follow up on a recommended re-weigh, failed to document refusals, and did not implement dietary interventions. Staff interviews confirmed inconsistent documentation and a lack of follow-up, while the nutrition at risk review system did not trigger intervention due to missing weight data.
A staff member did not perform hand hygiene before entering a resident's room and failed to wear a gown while providing suprapubic catheter care, despite an Enhanced Barrier Precautions sign indicating the need for PPE. Another staff member was initially unaware of the reason for the EBP sign until reviewing the care plan, which specified precautions for catheter care.
A resident assessed as at risk for elopement, with a high BIMS score, was able to remove her wander guard using scissors obtained from another resident and exited the facility undetected. Staff were unaware of her absence until notified by law enforcement, who found her in a nearby park approximately 45 minutes later. Documentation showed inconsistencies regarding the resident's wander guard status, and supervision measures in place did not prevent the elopement.
Multiple residents were not adequately protected from physical abuse when a resident with a history of aggressive behavior was able to repeatedly engage in altercations with others, resulting in injuries such as falls, lacerations, and bruising. Lapses in supervision and failure to follow abuse prevention protocols allowed these incidents to occur, as staff did not consistently provide required monitoring or intervene to prevent resident-to-resident conflicts.
The facility did not ensure medications were administered within the required time frame or to the correct residents, as evidenced by multiple instances of late medication administration and a medication error where one resident received another's medications. Several residents reported receiving medications late, particularly during night shifts, and audit reports confirmed repeated delays and missed doses. Facility policy requires medications to be given within one hour of the scheduled time and to the correct resident, but these standards were not consistently followed.
The facility did not maintain accurate and complete medical records for three residents involved in multiple physical altercations. After several incidents, there was no documentation in the medical records describing the events or assessing the physical and psychosocial condition of those involved, nor were interventions or responses recorded as required. Staff confirmed that such documentation should have been present, but no explanation was given for its absence.
The facility failed to store food according to professional standards, with several items found expired or lacking proper date labels. Additionally, non-food items were improperly stored on the floor, violating facility policy. A staff member acknowledged the issues but had not yet corrected them.
The facility failed to maintain a clean and safe environment for three residents, with issues such as exposed sheetrock, damaged flooring, and uncleanable surfaces. One resident's room was cluttered and dirty, with a broken electrical outlet cover and a sheet that had not been changed for weeks. Despite daily housekeeping visits, maintenance requests were not logged, and staff interviews revealed inconsistencies in cleaning practices and communication.
The facility failed to cover catheter bags for two residents, compromising their dignity. One resident was unaware of the option to cover the bag, while another expressed discomfort with the exposure. Staff acknowledged the requirement to cover bags but noted that CNAs sometimes neglected to do so. The facility did not provide a catheter care policy by the survey's end.
A resident self-administered insulin without supervision, contrary to the facility's policy requiring supervision and periodic assessment. The resident, who had been independently managing insulin and glucose levels, was not observed by nurses, and staff were unaware of the required assessment documentation. The facility's policy mandated quarterly evaluations, which were not conducted.
A facility failed to investigate a staff member accepting money from a resident for craft items, violating policy. Additionally, two residents reported missing personal items, with no specific policy in place to address such issues. Staff interviews revealed inadequate handling of grievances related to missing belongings.
A facility failed to report an abuse allegation in a timely manner when a resident was left unattended on the toilet, and another resident was transported naked in a common hallway. The initial report and investigation findings were submitted late to the State Survey Agency, violating the facility's policy on timely reporting of abuse and neglect.
A facility failed to thoroughly investigate an incident where a resident was transported naked to a shower room. The investigation lacked comprehensive documentation, including interviews with other residents and staff, and did not follow the facility's abuse policy. The incident led to one staff termination and a warning for another.
A resident who lost dentures seven years ago was not offered help to obtain new ones, leading to difficulty eating. Despite this, the MDS inaccurately indicated no dental issues. Staff involved in the MDS process were unaware of the resident's lack of dentures, and there was no formal process to ensure MDS accuracy.
The facility failed to develop baseline care plans within 48 hours for two residents, leading to deficiencies in addressing their immediate care needs. One resident's care plan was delayed, while another's lacked documentation for urinary catheter management, despite repeated tampering incidents.
The facility failed to implement comprehensive care plans for two residents, one requiring dialysis and another with dental and respiratory needs. The dialysis resident did not receive post-dialysis care, and their care plan lacked dialysis-related assessments. The second resident's care plan did not address the need for dentures or CPAP oxygen tubing changes, leading to difficulties in eating and potential respiratory issues.
A facility failed to complete an elopement evaluation for a resident at risk of elopement, who had attempted to leave the facility. The resident, with medical conditions including anoxic brain damage, was only oriented to person upon admission. Despite the resident's attempt to leave and subsequent use of a wander guard, the responsible party was not informed, leading to concerns about the resident's safety and supervision. The facility's policy required an elopement risk evaluation upon admission, which was not conducted.
A facility failed to change a resident's oxygen tubing as ordered, increasing the risk of respiratory infections. Observations revealed the tubing was dated months prior, and the resident reported it had never been changed. Staff interviews showed inconsistencies in the process and frequency of changing the tubing, with documentation in the TAR not consistently recorded, indicating a lack of adherence to protocol.
A facility failed to provide necessary pre and post-dialysis care for a resident, as staff did not take vitals or assess the access site upon the resident's return from dialysis. The resident's EHR showed no dialysis assessments since admission, and staff confirmed the absence of a care plan or physician order. This non-compliance with the facility's Hemodialysis Access Care policy posed potential harm, including hypotension, renal failure, and infection.
A certified medication aide II improperly administered subcutaneous medications, including Ozempic and glatiramer acetate, to a resident over several months. The aide was only permitted to administer prelabeled, pre-drawn insulin according to state law, but administered other subcutaneous medications, leading to a deficiency in compliance with regulations.
A resident without dentures experienced difficulty eating due to the facility's failure to address his dental needs. Despite the resident's challenges, staff did not inquire about or facilitate obtaining dentures, assuming he did not want them. The care plan noted oral health issues, but no action was taken to resolve them.
A resident undergoing dialysis experienced repeated issues with the facility's failure to accommodate his dietary preferences and intolerances. Despite clear instructions to avoid bananas, the resident was frequently given them, causing frustration. Additionally, the resident faced delays in receiving breakfast on dialysis days and reported spoiled lunches. The resident also had to retrieve his cranberry juice, which was a standing order, indicating a lapse in meeting his dietary needs.
The facility failed to provide written notices of transfer for three residents, as required. In one case, a resident's transfer notice was missing due to a shortage of forms. Another resident's transfer notice was not completed or scanned into the electronic medical record. A third resident was transferred multiple times without the necessary written notices. Staff interviews indicated that a lack of forms contributed to these deficiencies.
The facility failed to provide a Notice of Bed Hold to two residents or their representatives during hospital transfers. One resident's notice was unsigned, and another's electronic medical record lacked documentation of the notice on two occasions. Staff interviews revealed that the required process was not followed, and the facility's policy mandates providing bed hold information within one business day of an emergency transfer.
A cognitively impaired resident, at risk of elopement, was left unattended in a bathroom at a dialysis center by a facility transportation driver. The driver, lacking training for transfers, assumed medical staff were aware of the resident's presence. The resident was found hours later, having missed his dialysis appointment, and was later hospitalized for an unrelated issue.
The facility failed to maintain proper food storage and labeling practices, with undated, unlabeled, and expired items found in the kitchen's walk-in freezer and refrigerator. Staff member H admitted to lapses in monitoring due to personal absence, and there was confusion about temperature checks in resident unit areas. The facility's policy on refrigerator and freezer management was not consistently followed, contributing to the deficiencies observed.
A resident experienced significant pain due to the failure of the facility to administer HYDROcodone-Acetaminophen as ordered for chronic pain. The medication was scheduled to be given five times a day, but doses were missed, and the reasons were not documented in the MAR. The staff member responsible reported forgetting to administer the medication.
A resident's room had a damaged wall and shelf, which were not repaired despite the resident's complaints. Maintenance staff were aware of the issue and had informed nursing staff that the room needed to be vacated for repairs, but the request was not completed in the Maintenance Request Log.
Facility staff failed to ensure a PASARR document was completed for a resident who was severely cognitively impaired and receiving multiple medications. The document was requested but not provided, and a staff member indicated the resident had transferred from a closed facility, leading to a lack of access to medical records.
A facility failed to develop a baseline care plan within 48 hours for a newly admitted resident who is blind and has chronic leg wounds. The resident's immediate needs, including pain management and wound care, were not documented in the EHR. The MDS nurse responsible for the care plan was no longer employed, and the facility has since changed its process to assign this task to the nurse completing the admission assessment.
A facility failed to provide meaningful activities and one-to-one interactions for a mostly bedridden and blind resident. The resident reported staying in bed due to leg pain and not participating in any activities or receiving visits from the Activities Department. A review of the resident's EHR showed a lack of timely activity assessment and care plan addressing her activity needs. A staff member acknowledged that the previous Activity Director forgot to conduct the assessment.
The facility failed to lock a storage room containing a sharp object, posing a risk to wandering residents. Additionally, a resident with mobility issues was not consistently assisted in transferring from bed to chair for meals, despite care plan instructions to prevent aspiration pneumonia. Staff interviews revealed inconsistencies in practice and documentation of the resident's transfer refusals.
A facility failed to implement a comprehensive care plan for a resident with oxygenation issues, leading to inappropriate use of ordered respiratory equipment. The resident reported that their oxygen concentrator was not functioning for two weeks, yet staff were unaware of the issue. The care plan lacked goals or interventions for the use of oxygen with BPAP at night, despite the resident's medical history of obstructive sleep apnea and other respiratory conditions. The facility's policy on oxygen administration was not followed, contributing to the deficiency.
A resident's dietary preferences were not followed by the facility's dietary staff, despite clear communication and documentation of these preferences. The resident, who disliked carrots and had standing orders for coffee with meals, reported receiving meals with carrots and having to retrieve his own coffee. Staff interviews revealed that meal slip orders were sometimes missed when staff were rushing.
The facility failed to provide written notices of transfer reasons to two residents or their representatives. One resident was hospitalized twice for sepsis and a UTI, and another was transferred after a fall and head injury. Staff indicated that administration was responsible for issuing these notices, but none were provided, contrary to facility policy.
The facility failed to provide required bed hold notices to two residents prior to hospital transfers. One resident was hospitalized twice for sepsis and a UTI, and another was transferred after a fall. Staff interviews revealed confusion about responsibility for issuing notices, and the facility's policy was not followed.
A resident was denied re-entry to a facility after leaving the hospital AMA, despite administrative instructions to allow him to stay. The resident, who was weak and recently diagnosed with cancer, was left outside in inclement weather for several hours. Staff failed to follow directives and showed a lack of concern, resulting in the resident being taken to the hospital by police.
The facility failed to report a significant event where a resident was denied reentry after leaving a hospital AMA, resulting in the resident being left outside and later taken by police. Additionally, the facility did not report findings of several incidents, including falls and abuse, to the State Survey Agency within the required timeframe. Miscommunication and lack of awareness during a change in administration contributed to these reporting failures.
Failure to Timely Report Alleged Abuse and Submit Investigation Findings
Penalty
Summary
The facility failed to timely report an allegation of sexual abuse to the State Survey Agency (SSA) and failed to submit investigation findings for multiple abuse-related events within required timeframes. For one resident, behavior progress notes documented that the resident had repeatedly been removed from female residents' rooms and had been rubbing the legs of other female residents, with staff repeatedly correcting and educating him on inappropriate behavior. A staff member later identified that this behavior should have been reported as a reportable event to the SSA but had not been. In a specific incident, a staff member observed this resident placing his hand on another resident's thigh while assisting her with eating, asked him to remove his hand, and reported the behavior to the nurse on duty after it recurred. The nurse documented the behavior in the resident's behavior charting but did not report the allegation to the SSA, despite having received training on forms of abuse and reporting requirements. The facility also failed to submit investigation findings to the SSA within the required five working days for several previously reported events. One facility-reported event involved a verbal altercation between two residents, for which the investigation findings were due to the SSA by a specified date but were submitted one day late. Another facility-reported event involved a resident's allegation of verbal abuse by a staff member, where the investigation findings were also submitted one day past the due date. The administrator reported that an Administrator in Training was responsible for submitting reportable events and investigation findings and that alerts were received when findings were due, but could not explain why the findings were submitted late. These actions and inactions were inconsistent with the facility's Abuse, Neglect, and Exploitation policy, which required reporting allegations of abuse to appropriate agencies within specified timeframes and reporting investigation results within five working days of the incident, as required by state agencies.
Failure to Investigate Resident-to-Resident Inappropriate Contact
Penalty
Summary
The deficiency involves the facility’s failure to investigate an allegation of resident-to-resident inappropriate, nonconsensual contact. A behavior progress note for resident #73 dated 12/14/25 documented that this resident had repeatedly been removed from female residents’ rooms and had been rubbing the legs of other female residents. The note indicated that staff had repeatedly corrected and educated the resident on this inappropriate behavior. Despite this documentation, there was no evidence that the specific incident involving residents #46 and #73 on 12/14/25 was reported to the State Survey Agency or investigated by the facility. During an interview on 2/24/26, staff member A reported that while reviewing the former resident #73’s chart in connection with a possible return to the facility, they discovered a progress note describing a reportable event involving residents #46 and #73 that had not been reported or investigated. Staff member A stated they had not been aware of the incident prior to this chart review. Review of the facility’s incident reports confirmed that the event between residents #46 and #73 on 12/14/25 was not included among incidents reported or investigated. This failure occurred despite the facility’s written Abuse, Neglect, and Exploitation policy, which requires an immediate investigation upon suspicion or reports of abuse, neglect, or exploitation, including identifying responsible staff, interviewing all involved persons and witnesses, determining whether abuse or related mistreatment occurred, and thoroughly documenting the investigation.
Inadequate Burn Wound Assessment, Treatment Documentation, and Follow-Through
Penalty
Summary
Licensed nursing staff failed to provide wound care and documentation in accordance with professional standards for a resident who sustained first- and second-degree burns to the lower abdomen, groin, and right hip after spilling hot soup. Initial documentation on the day of injury described the burn locations, sizes, and blistering, and indicated that the provider evaluated the burns and gave instructions for new orders, including dressing applications. Subsequent nursing notes on selected days documented that the burn area was cleaned, Bacitracin applied, and dressings placed, with brief comments such as "no signs of infection" and that the resident tolerated treatment. However, these notes did not consistently address all burn areas or provide detailed assessments of the wounds, including classification, measurements, wound assessment, wound edges, odor, pain, or signs of infection, nor did they evaluate whether the treatment was beneficial. Record review showed multiple dates with no wound status notes, including several days immediately following the injury and a prolonged gap until the wound was later documented as resolved. The wound management nurse had left the facility unexpectedly, and the nurse who assumed wound responsibilities reported she was unaware of the resident’s wound until weeks later, when she first assessed it and found it resolved. The Medication Administration Record for the month showed that ordered daily dressing changes to the right lateral hip burn site were not documented as completed on eight of 21 days. The facility’s own wound treatment management policy required documentation of treatments and ongoing assessment of wound effectiveness, and professional standards cited by the American Nurses Association emphasized the need for clear, accurate, and accessible nursing documentation, which were not met in this case.
Failure to Ensure Resident's Right to Be Free from Physical Restraints
Penalty
Summary
A resident with a left below-the-knee amputation was observed with their stump secured to a wheelchair footrest using a tan compression wrap, which the resident was unable to remove independently. Staff interviews revealed that the compression wrap had been used for some time to keep the stump in place because the resident would not wear their prescribed brace. Multiple staff members acknowledged that there was no physician's order for the use of the compression wrap as a restraint, and no assessment or documentation was completed regarding its use. Staff also indicated a lack of awareness about the need for documentation or assessment, and some staff were under the impression that securing the stump in this manner was permissible. Record reviews confirmed the absence of a physician's order, assessment, or documentation related to the use of the compression wrap as a restraint. There was no evidence of monitoring, release, or skin assessment for the area where the wrap was applied. Additionally, therapy evaluations did not address the use of the compression wrap for stump positioning. The facility's own policy prohibits the use of physical restraints without proper assessment, documentation, and physician authorization, none of which were present in this case.
Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
A deficiency occurred when the facility failed to complete a baseline care plan within the required 48-hour timeframe for a newly admitted resident. The resident, who had a wound and experienced forgetfulness and confusion, was observed at the nursing station wearing soiled clothing and reported needing assistance with dressing and hygiene. Documentation showed that the resident's needs for activities of daily living varied, requiring different levels of assistance, but no baseline care plan was in place to address these needs within the mandated period. Interviews with staff confirmed that a baseline care plan had not been completed for the resident, and at the time of the survey, the care plan in the electronic medical record was still blank. The facility's policy required that a baseline care plan be developed and implemented within 48 hours of admission, including essential healthcare information to properly care for the resident. The lack of a timely baseline care plan had the potential to affect all new admissions.
Failure to Develop and Implement Comprehensive Oral Care Plan
Penalty
Summary
The facility failed to develop and implement a person-centered, comprehensive care plan that adequately assessed and addressed the dental status and oral care needs of a resident. Observations revealed that the resident was lacking teeth and relied on dentures, which had been lost by the facility and replaced by an old pair provided by family. Interviews with staff indicated inconsistent practices regarding oral and denture care, with some staff believing that if dentures were already in place, oral care was unnecessary. The resident's care plan did not specify whether the resident had no teeth or dentures, nor did it outline the specific type of oral care required. Further interviews with family members revealed that the facility had not replaced the lost dentures as expected, and that family members had to clean the resident's dentures themselves due to staff neglect. The facility's policy required comprehensive, person-centered care plans that included resident-specific interventions, but the care plan for this resident lacked essential details about dental status and oral care needs. Documentation and communication regarding refusals of care and the resident's oral health status were also found to be insufficient.
Failure to Revise Care Plan After Resident Refusal and Use of Restraint
Penalty
Summary
The facility failed to revise a resident's care plan after the resident refused to wear a prescribed brace and staff began using a compression wrap to secure the resident's left below-knee amputation stump to the wheelchair leg rest. Observations showed the resident was unable to remove the compression wrap and was seen pulling at it. Staff interviews revealed that the use of the compression wrap was not documented in the care plan, and refusals of the brace were not consistently recorded or reported. Staff also indicated that the use of the compression wrap had been ongoing and was not based on a documented care plan intervention. Review of the resident's comprehensive care plan showed no updates or interventions related to the use of the compression wrap as a restraint or the resident's refusal to wear the brace. The care plan only referenced the brace and monitoring under it, with no mention of the alternative intervention or associated risks. Facility policies required the care plan to be reviewed and revised by the interdisciplinary team and updated to reflect any restraint use, but these steps were not followed for this resident.
Failure to Resolve Resident Grievances Regarding Delayed Meal Service
Penalty
Summary
The facility failed to resolve resident grievances in a timely manner regarding delayed meal service, as evidenced by multiple residents reporting consistent and significant delays in receiving their meals. Observations and interviews revealed that meals were often served two or more hours late, with residents stating that their complaints did not result in any changes. Staff interviews confirmed that the dietary department was short-staffed, leading to prolonged wait times for meals. Residents reported that the delays had been ongoing for months and that their concerns were not addressed or communicated back to them. Review of facility grievance forms documented repeated complaints about late meals and lack of consistency in meal service. The forms indicated that residents were waiting over an hour for meals and that the kitchen was short-staffed, causing delays. Despite these documented grievances, the facility did not provide evidence that residents were kept informed of progress toward resolution or that prompt efforts were made to resolve the issues, as required by facility policy. Posted mealtimes were not adhered to, further supporting the deficiency in timely grievance resolution.
Failure to Notify Ombudsman of Resident Transfers and Discharges
Penalty
Summary
The facility failed to provide timely notification to the State Long-Term Care Ombudsman regarding the transfer and discharge of three residents. Interviews revealed that the ombudsman had not received any transfer or discharge notifications from the facility, despite having previously requested such notifications. Staff responsible for the notifications was unaware of the requirement and had not been sending the necessary information to the ombudsman. Record reviews confirmed that the medical charts for the affected residents did not contain evidence that the required notifications had been made at the time of their transfer or discharge. Specifically, one resident was transported to the Emergency Department, admitted to the hospital, and later returned to the facility, but there was no documentation of ombudsman notification. Two other residents were discharged from the facility, and their charts also lacked evidence of notification to the ombudsman. The deficiency was identified through interviews with staff and the ombudsman, as well as a review of resident records and facility correspondence.
Failure to Provide Timely Meal Service Due to Inadequate Staffing
Penalty
Summary
The facility failed to provide sufficient support personnel to ensure that meals were served to residents in a timely manner, as required by posted mealtimes. Multiple residents reported that meals were consistently late, with one resident stating that lunch was just being served at 2:15 p.m., well after the scheduled time. Another resident expressed frustration at having to rush through breakfast to attend church, while a different resident noted receiving evening medications before dinner due to the meal being delayed. Several residents indicated that late meals caused them to miss or rush through activities, and one resident specifically mentioned that dinner had been served as late as 7:00 p.m. over the past two months. Residents also reported that staffing shortages were a persistent issue and that grievances about the problem had not led to improvements. Staff interviews during a resident council meeting confirmed that meal delays were related to staffing concerns. One staff member acknowledged ongoing hiring attempts that had not resolved the issue, and another encouraged residents to eat in the dining room for faster service, as meal delivery to rooms was slower. Observations confirmed that all available staff were assisting with breakfast tray service in the dining room, further indicating a lack of adequate support personnel to meet the needs of all residents in a timely manner.
Failure to Provide Proper Suprapubic Catheter Care and Maintenance
Penalty
Summary
Staff failed to provide proper suprapubic catheter care and maintenance for a resident, resulting in an unidentified and untreated skin breakdown around the catheter insertion site. The resident reported that catheter care was inconsistently performed, with cleaning occurring only about every other brief change, and that staff often used alcohol wipes instead of the facility-approved cleanser or mild soap and water. The resident also noted frequent bladder infections, leakage, and that the catheter was not consistently secured to prevent pulling, which contributed to skin redness and maceration. During observations, staff were seen using alcohol wipes to clean the catheter and insertion site, and the catheter was not secured afterward. Redness and maceration the size of a nickel were observed around the insertion site, and the resident stated this condition was ongoing and worsened when the catheter was not secured. Interviews with staff revealed a lack of clarity regarding the specific cleaning procedures and products to use for suprapubic catheter care, with some staff unaware of the resident's care orders or the presence of skin breakdown. Documentation in the care plan and facility policy indicated that staff should inspect the insertion site for signs of infection, use approved cleansers, and secure the catheter to prevent pulling. However, these procedures were not consistently followed, and communication lapses were evident, as some nurses were not informed of the skin breakdown. The failure to adhere to established catheter care protocols and to report and address skin issues led to the deficiency.
Failure to Address Severe Weight Loss and Document Interventions
Penalty
Summary
The facility failed to adequately address a severe weight loss in one resident by not following up on a recommended re-weigh, failing to document refusals, and not implementing dietary interventions. The resident's weight records showed a significant drop of over 10% within two months, with missing or refused weights documented for several months. Despite a registered dietitian noting dramatic weight loss and recommending a re-weigh, there was no follow-up documentation or evidence of further dietary intervention. Additionally, the resident's treatment administration record and nursing progress notes lacked consistent documentation of weight refusals or actions taken. Interviews with staff revealed that the resident frequently refused to be weighed and had a history of frustration with weight monitoring, especially after previous hospice care. Staff acknowledged that without a current weight, the nutrition at risk review system did not flag the resident for intervention. The resident, who had end-stage COPD and was on hospice, reported difficulty eating due to shortness of breath. No nutrition at risk meeting notes were available for the period in question, and the facility's tracking system failed to ensure appropriate follow-up for the resident's weight loss.
Failure to Follow Infection Control Protocols During Catheter Care
Penalty
Summary
Staff failed to follow proper infection control practices during suprapubic catheter care for a resident. Specifically, a staff member entered the resident's room without performing hand hygiene, touched items in the room, and then exited to perform hand hygiene only after contact had already occurred. The same staff member performed suprapubic catheter care without wearing a gown, despite the presence of an Enhanced Barrier Precautions (EBP) sign on the resident's door, which indicated the need for gown and glove use during high-contact care activities such as catheter care. Another staff member was unaware of the reason for the EBP sign until reviewing the resident's care plan, which confirmed it was related to the suprapubic catheter. Facility policy required the use of gowns and gloves for such care to reduce transmission of multidrug-resistant organisms.
Resident Elopement Due to Inadequate Supervision and Wander Guard Removal
Penalty
Summary
A resident with a high Brief Interview for Mental Status (BIMS) score of 13, who was assessed as being at risk for elopement and wandering, was able to remove her wander guard by cutting it off with scissors obtained from another resident. The resident then exited the facility through the main doors without staff knowledge and was later found by local law enforcement in a park across the street. The incident report indicated that staff were not aware of the resident's absence until notified by police, at which point the resident had been missing for approximately 45 minutes. Review of facility documentation showed that the resident's most recent Minimum Data Set (MDS) did not indicate she was wearing a wander guard, despite a prior risk assessment identifying her as at risk for elopement. Staff interviews revealed that the resident was new to the facility, enjoyed social activities, and was generally supervised through hourly rounds and 15-minute checks following the incident. The facility's monitoring and supervision failed to prevent the resident from obtaining scissors, removing her wander guard, and leaving the premises undetected.
Failure to Prevent and Monitor Resident-to-Resident Abuse
Penalty
Summary
The facility failed to prevent and protect multiple residents from abuse and neglect, specifically in cases involving resident-to-resident altercations. On several occasions, one resident with a history of intrusive and aggressive behaviors was able to physically engage with other residents, resulting in injuries. In one incident, this resident approached another in a common area, grabbed him by the shirt, and pulled him from his wheelchair, causing both to fall to the ground. The victim was not exhibiting any provoking behaviors at the time of the incident. Further review revealed that the same resident entered another resident's room on two separate occasions, leading to physical altercations. In one instance, the resident entered a shared room, approached a roommate, and was physically removed by another resident, resulting in a fight. In another incident later that night, after being put to bed and no longer under one-to-one supervision, the resident again entered the same room, leading to a physical confrontation that caused visible injuries, including a laceration near the eye and chest bruising to one of the residents involved. Staff interviews confirmed lapses in supervision, with one staff member noting that the assigned one-to-one monitor was not present when the resident left his bed. The facility's policy required increased supervision and ongoing assessment for residents with behaviors that may lead to conflict, but these measures were not consistently implemented. The lack of adequate monitoring and failure to maintain a safe environment directly contributed to repeated altercations and injuries among residents, demonstrating a breakdown in the facility's abuse prevention protocols.
Failure to Administer Medications Timely and to Correct Residents
Penalty
Summary
The facility failed to ensure that medications were administered within the required time frame and to the correct residents, as evidenced by multiple instances of late medication administration and medication errors. Several residents reported receiving their medications late, particularly during night shifts and weekends. Medication Administration Audit Reports for multiple residents showed that medications were often given well outside the one-hour window before or after the scheduled administration time, with some doses being missed entirely or administered several hours late. In addition to late administration, there were documented cases where a resident was given another resident's medications. Specifically, one resident received evening medications intended for another resident, including melatonin, memantine, tamsulosin, and trazodone, in addition to their own prescribed medications. This error was noted in the nursing progress notes, and the affected resident reported feeling excessively sleepy and slept late the following day. The records did not clarify whether the resident who was supposed to receive those medications actually received the correct doses. The facility's policies on medication administration and medication errors require adherence to the six rights of medication administration, including the right resident and right time, and specify that medications should be administered within 60 minutes of the scheduled time. Despite these policies, the audit reports and interviews confirm that these standards were not consistently met for several residents over multiple days, resulting in both late and incorrect medication administration.
Failure to Document Resident Altercations and Assessments in Medical Records
Penalty
Summary
The facility failed to maintain accurate and complete medical records for three residents involved in multiple altercations. Specifically, after a reported incident where one resident was pulled from a wheelchair by another, there was no documentation in the medical records of either resident describing the incident or assessing their physical and psychosocial condition. Additionally, there was no record of interventions implemented to protect the residents or the response to those interventions. In a subsequent incident involving the same resident as the aggressor and two other residents as victims, the medical record for one of the victims did not include a description of the incident or an assessment of their condition following the altercation. A third altercation occurred later the same day, resulting in injuries to one resident, but the nursing progress notes again failed to document the incident or the resident's condition immediately after. The only related note appeared the following day, describing the injuries but not the circumstances of the altercation. Staff interviews confirmed that each resident involved in such incidents should have corresponding documentation in their medical records, but no explanation was provided for the lack of progress notes regarding these events.
Improper Food Storage and Labeling
Penalty
Summary
The facility failed to store food in accordance with professional standards, as observed during a survey. Various food items in the kitchen storage were found to be improperly labeled or expired. Specifically, open containers of Worcestershire sauce, chili powder, Tuscan dressing, and other items were either expired or lacked proper dating. Additionally, several food items such as pancake mix, parsley flakes, and pepperoni were open without any date labels. This lack of proper labeling and dating of food items indicates a failure to adhere to the facility's policy on food storage, which requires all food to be labeled and dated with an appropriate use-by date. Furthermore, the facility was found to be storing non-food items improperly. Cases of coffee lids, foam containers, portion cups, dinner napkins, and other paper goods were stored on the floor in the hallway and closet, contrary to the facility's policy that requires food and related items to be stored at least six inches off the floor. During an interview, a staff member acknowledged awareness of these issues and mentioned plans to address them, but at the time of the survey, the deficiencies remained uncorrected.
Failure to Maintain a Safe and Sanitary Environment
Penalty
Summary
The facility failed to maintain a clean, safe, and sanitary environment for three residents, resulting in deficiencies in their living conditions. Resident #28's room had a significant tear in the sheetrock, exposing powdered sheetrock and creating an uncleanable surface. Additionally, the bathroom paint was peeling around the toilet, further contributing to the unsanitary conditions. Resident #28 expressed dissatisfaction with the state of her room, indicating awareness of the issue. Resident #72's bathroom floor had a large hole in the linoleum, with worn edges that had discolored over time. The bathroom walls also had multiple areas where the sheetrock was exposed, creating additional uncleanable surfaces. Despite these issues, there were no maintenance requests logged for repairs in either resident #28 or #72's rooms, indicating a lack of action from the facility to address these concerns. Resident #29's room was observed to be dirty and cluttered, with stained floors and a broken electrical outlet cover. The resident's bed had a dirty, threadbare sheet that had not been changed for two to three weeks, despite daily housekeeping visits. Staff interviews revealed inconsistencies in cleaning practices and communication regarding maintenance needs. The maintenance staff acknowledged challenges in keeping up with repairs and noted that room audits were conducted monthly, but no maintenance requests were documented for resident #29's room issues.
Failure to Cover Catheter Bags Compromises Resident Dignity
Penalty
Summary
The facility failed to maintain resident dignity by not covering catheter bags for two residents. During observations, one resident's catheter bag was attached to the bed and uncovered, with visible yellow urine. The resident was unaware that covering the bag was an option. Another resident's catheter bag was also exposed, and she expressed discomfort with it being uncovered. Interviews with staff members revealed that they were aware of the requirement to cover catheter bags for dignity, but noted that CNAs sometimes did not take the time to find covers. Despite requests, the facility did not provide a policy and procedure for catheter care, including the use of catheter bag covers, by the end of the survey.
Failure to Supervise Self-Administration of Insulin
Penalty
Summary
The facility failed to supervise the self-administration of insulin for one resident, increasing the risk of a negative outcome if the medication and monitoring were not handled properly. The resident, who had been self-administering insulin and monitoring blood glucose levels independently for years, reported that nurses did not observe him during these activities. The resident demonstrated the use of a continuous glucose monitoring system and stated that he informed the nurses of his blood glucose levels when asked. Staff interviews revealed that the facility lacked a documented self-administration of medication assessment for the resident. Although there was a policy in place requiring periodic reevaluation of a resident's ability to self-administer medications, staff members were unsure of the assessment's location or documentation. The resident's Medication Self-Administration Safety Screen indicated that self-administration should occur with supervision, yet no such supervision was provided. The facility's policy also required quarterly checks during MDS reviews, which were not documented for this resident.
Deficiencies in Handling Resident Belongings and Financial Transactions
Penalty
Summary
The facility failed to conduct a thorough investigation into an incident involving a staff member accepting money from a resident in exchange for craft items. Resident #41 expressed concern about a staff member who brought in craft supplies and accepted nearly fifty dollars from her, despite the facility's policy prohibiting staff from accepting money from residents. The resident reported the incident to the administrator, but no formal documentation or investigation was conducted at the time. Staff member U admitted to accepting money from residents for supplies and was previously informed by the administration that such actions were not allowed. Additionally, the facility did not adequately address the issue of missing personal items for residents #37 and #280. Resident #37 reported that several personal items, including marking pens and clothing, had gone missing, despite filing grievances. Resident #280 also reported a significant reduction in personal clothing since admission to the facility. Staff interviews revealed a lack of a specific policy for handling missing items, and the facility's grievance policy did not effectively address the residents' concerns. The facility's documentation indicated that employees are not permitted to accept tips or gifts from residents and that personal financial transactions with residents are prohibited. However, the lack of a formal investigation and documentation of the incidents involving resident #41 and the missing items for residents #37 and #280 highlights deficiencies in the facility's handling of resident belongings and financial transactions.
Failure to Timely Report Abuse and Neglect Incidents
Penalty
Summary
The facility failed to report an abuse allegation involving a resident who was left unattended on the toilet by a CNA, believing another CNA would assist the resident. The incident occurred at 7:30 p.m., and the resident was later found crying in her room. The initial report of the alleged neglect was not submitted to the State Survey Agency until two days later. The final report indicated that a staff member was terminated for failing to report the incident to the facility abuse coordinator. In another incident, a resident was transported naked and uncovered from his room to the shower room by staff, which was captured on video footage. The facility's investigation findings were submitted a day late to the State Survey Agency. The facility's policy requires that all alleged violations involving abuse, neglect, or mistreatment be reported immediately, but no later than two hours if serious bodily injury is involved, or within 24 hours if not. The delay in reporting and submitting findings indicates a failure to adhere to these reporting timelines.
Incomplete Investigation of Resident Incident
Penalty
Summary
The facility failed to conduct a complete investigation of a reported incident involving a resident who was transported naked and uncovered to a shower room by staff. The incident, which occurred on 12/30/24, was reported, and one staff member was terminated while another received a final written warning. However, the facility did not maintain thorough documentation of the investigation process. The documentation provided included only two written statements from staff who learned of the incident from the resident and an unlabeled document with minimal information about the staff member who received a warning. The facility's investigation was incomplete as it did not include interviews with other residents and staff members to gather additional details or identify patterns of behavior, as initially stated in the incident description. Furthermore, the facility did not provide documentation of any care plan review or ongoing monitoring of the resident's emotional and physical health. The facility's policy on abuse investigations requires the administrator or designee to conduct interviews and document summaries, but this was not adequately followed, and the results were not reported to the State Survey Agency within the required timeframe.
Inaccurate Dental Assessment for Resident
Penalty
Summary
The facility failed to accurately assess the dental needs of a resident during the comprehensive Minimum Data Set (MDS) assessment. The resident, who lost his dentures seven years ago, reported not being offered assistance to obtain new dentures. During an observation, the resident was unable to chew a piece of broccoli and expressed difficulty eating certain foods without dentures. Despite these issues, the resident's readmission screening assessment inaccurately reflected that he had upper and lower dentures that fit, and the MDS indicated no problems with chewing. Staff member M, who was involved in the MDS admission process, stated that the resident was screened for dental needs during admission and most recently six weeks prior, with no issues noted. However, she was unaware of the resident's lack of dentures. The facility's policy on resident assessment emphasizes the importance of accurately describing a resident's capabilities and impairments to plan appropriate care. The lack of a formal process for ensuring MDS accuracy contributed to the oversight in assessing the resident's dental needs.
Failure to Implement Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for two residents, leading to deficiencies in addressing their immediate care needs. Resident #75 was admitted to the facility, but the baseline care plan was not completed until several days later. Interviews with staff members revealed that nursing staff were responsible for completing these care plans, but there was no clear explanation for the delay in Resident #75's case. Resident #282, who had a history of acute kidney failure and urinary retention, was observed with a urinary catheter but lacked documentation in the care plan regarding its use. The resident had repeatedly tampered with the catheter, leading to multiple changes. Despite these incidents, the care plan did not reflect the necessary interventions to manage the catheter effectively. The facility's policy required a baseline care plan to be developed within 48 hours of admission, which was not adhered to in these cases.
Failure to Implement Comprehensive Care Plans for Dialysis and Dental/Respiratory Needs
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident requiring dialysis, leading to a lack of post-dialysis care. Despite the resident attending dialysis sessions three times a week, staff did not take vital signs, assess the dialysis site, or perform any post-dialysis checks. The resident's electronic health record (EHR) showed no dialysis assessments since admission, and the comprehensive care plan did not include dialysis care. Staff were unable to locate any care plan or physician orders related to dialysis, despite the resident having been on dialysis since before admission. Another resident's care plan failed to address dental and respiratory needs. The resident used a CPAP machine with oxygen tubing that had not been changed since the previous year, and staff did not check the equipment. The resident also had difficulty eating due to the absence of dentures, which was not addressed in the care plan. Staff interviews confirmed that these needs were not documented in the resident's assessments or care plan, leading to inadequate care for the resident's respiratory and dental needs.
Failure to Complete Elopement Evaluation for At-Risk Resident
Penalty
Summary
The facility failed to complete a thorough elopement evaluation for a resident who was at risk of elopement and had attempted to leave the facility. The resident, who was only oriented to person upon admission, had pertinent medical diagnoses including anoxic brain damage, acute kidney failure, and urinary retention. Despite these conditions, there was no wander/elopement risk evaluation found in the resident's electronic medical record. The resident had attempted to leave the facility, and a wander guard device was subsequently ordered for safety, but the responsible party was not notified of this measure. Interviews and record reviews revealed that the resident's responsible party was concerned about the lack of supervision and the resident's safety, especially after the resident had two falls and attempted to leave the facility within two weeks of admission. The facility's policy required a wander/elopement risk evaluation for all residents upon admission, which was not completed in this case. This oversight led to the responsible party's worry about the resident's safety and the adequacy of supervision provided by the facility.
Failure to Change Oxygen Tubing as Ordered
Penalty
Summary
The facility failed to change the oxygen tubing for a resident as ordered, which had the potential to increase the risk of respiratory infections. During multiple observations, the resident's oxygen tubing was found to be dated several months prior, indicating it had not been changed as per the facility's policy or the physician's order. The resident, who used a CPAP machine at night, reported that no one had checked or changed his oxygen tubing since he began using it. Interviews with staff revealed inconsistencies in the process of changing and tracking oxygen tubing. Staff members provided conflicting information about the frequency and responsibility for changing the tubing, with some stating it should be changed every 30 days, while others mentioned every two weeks. The facility's policy required oxygen tubing to be dated and labeled when new tubing is applied and changed weekly or according to the physician's order. However, documentation in the resident's Treatment Administration Record (TAR) showed that the tubing change was not consistently recorded, highlighting a lack of adherence to the established protocol.
Failure to Provide Pre and Post-Dialysis Care
Penalty
Summary
The facility failed to provide necessary pre and post-dialysis care for a resident receiving dialysis, which was identified during an observation, interview, and record review. The resident, who had been on dialysis since November 11, 2024, reported that staff did not take her vitals upon returning from dialysis, did not assess her access site, and no nurse checked on her post-dialysis. A review of the resident's electronic health record (EHR) showed no dialysis assessments had been completed since her admission on January 3, 2025. Staff member C confirmed the absence of a care plan, post-dialysis assessments, or a physician order in the EHR. The facility's policy on Hemodialysis Access Care, dated December 19, 2016, requires documentation of the presence of bruit and thrill every shift and completion of pre and post-assessment sections on the dialysis communication form. However, staff member B outlined that the procedures were not followed, as the nurse did not complete the necessary dialysis assessment upon the resident's return. This lack of adherence to the facility's policy and procedures resulted in a potential for harm, including hypotension, renal failure, and infection at the access site.
Improper Administration of Subcutaneous Medications by Certified Medication Aide II
Penalty
Summary
The facility failed to ensure that scheduled subcutaneous medications were administered by staff licensed to do so, affecting one resident out of a sample of 29. A certified medication aide II administered prefilled subcutaneous medications, including Ozempic and glatiramer acetate, over several months. The facility's staff member D acknowledged that the medication aide II was only permitted to administer prelabeled, pre-drawn insulin subcutaneously according to the Montana Code Annotated 2023. Despite this, the medication aide II administered Ozempic injections 17 times over five months and glatiramer acetate injections 135 times over six months. The facility's job description for a certified medication aide II indicated that they could deliver routine oral, inhalation, and topical medications under the supervision of a licensed nurse unless otherwise allowed by state law. However, the Montana Code Annotated 2023 specifies that a medication aide II may not administer parenteral or subcutaneous medications except for prelabeled, pre-drawn insulin. This discrepancy led to the improper administration of subcutaneous medications by a certified medication aide II, which was not in compliance with state regulations.
Failure to Address Resident's Denture Needs
Penalty
Summary
The facility failed to meet the oral health needs of a resident, who had been without dentures throughout his residency. The resident expressed difficulty in eating certain foods, such as overcooked meat and undercooked vegetables, due to the lack of dentures. Despite these challenges, the staff had not inquired about the resident's need for dentures, nor had they facilitated the process for obtaining them. The resident's care plan indicated the presence of oral/dental health problems, yet there was no follow-up to address these issues. Interviews with staff revealed a lack of proactive measures in assessing and addressing the resident's dental needs. Staff members assumed the resident did not want dentures because he had not explicitly requested them. The responsibility for scheduling dental appointments was placed on the resident, with staff stating that dental care was discussed during admission and readmission assessments. However, there was no evidence that the resident's need for dentures was adequately assessed or addressed in his care plan, leading to a deficiency in providing necessary dental care.
Failure to Accommodate Dietary Preferences for Dialysis Resident
Penalty
Summary
The facility failed to accommodate a resident's dietary preferences and intolerances, specifically for a resident undergoing dialysis. On multiple occasions, the resident was provided with bananas despite a clear note on the breakfast diet slip indicating 'ABSOLUTELY NO BANANA.' The resident expressed frustration over receiving bananas with breakfast, which he did not want due to his dialysis treatment. Additionally, the resident reported that his breakfast was sometimes delayed on dialysis days, preventing him from eating before his treatment. Furthermore, the lunches provided were reportedly spoiled by the time he could consume them during dialysis. The resident also experienced issues with receiving cranberry juice, which was a standing order on his diet slip. On one occasion, the resident had to retrieve the juice himself, expressing frustration over the oversight. Staff member O stated that she followed the meal ticket for the resident's allergies, preferences, and dislikes, and mentioned that the dietitian occasionally made changes. However, the resident's care plan, which focused on dialysis, indicated that he should receive an appropriate diet lunch before leaving for dialysis, a requirement that was not consistently met.
Failure to Provide Written Notice for Transfers
Penalty
Summary
The facility failed to provide written notice of the reason for a facility-initiated transfer to three residents or their representatives. For one resident, there was no documentation of a Notice of Transfer in the electronic medical record, and the facility was unable to provide this documentation upon request. Staff interviews revealed that the facility had run out of transfer forms during the time of the resident's transfer, which contributed to the lack of documentation. Another resident was transported to the hospital for an acute change in condition, but the medical record did not show that the required written notice was provided. A staff member indicated that the notice should have been completed and scanned into the electronic medical record, but it was not. Similarly, a third resident was transferred to the hospital on multiple occasions, but the facility failed to provide the necessary written notices for these transfers. Staff interviews suggested that a shortage of forms may have been a factor in the failure to complete the notices.
Failure to Provide Notice of Bed Hold for Hospital Transfers
Penalty
Summary
The facility staff failed to provide a Notice of Bed Hold to two residents or their representatives, which is a requirement when residents are transferred to a hospital or take therapeutic leave. In the case of one resident, the Bed Hold Notice dated December 22, 2024, was not signed by either the resident or their representative. During an interview, a staff member indicated that the Notice of Bed Hold should be signed by someone, either a Power of Attorney (POA) or verbally over the phone, but this was not done for the resident in question. For another resident, the electronic medical record did not show that a Notice of Bed Hold was provided on two separate occasions when the resident was transferred to a hospital. A staff member stated that the Notice of Bed Hold should be completed by a nurse and scanned into the resident's electronic medical record, but this was not done for the resident's transfers on September 24, 2024, and December 11, 2024. The facility's policy requires that information concerning the bed hold policy be provided within one business day of an emergency transfer, but no documentation was available to confirm compliance with this policy.
Resident Left Unattended at Dialysis Center
Penalty
Summary
A facility staff member failed to ensure the safety and supervision of a cognitively impaired resident who was at risk of elopement during transport to a dialysis appointment. The resident, who required supervision due to severe cognitive impairment and poor safety awareness, was left unattended in a bathroom at the dialysis center by the transportation driver. The driver, who was not trained to assist with transfers, left the resident in the bathroom and exited the building, assuming that the medical staff was aware of the resident's presence because they had unlocked the door remotely. The resident was discovered in the bathroom by dialysis center staff approximately four hours later, having missed his dialysis appointment. The resident was calm and was transported back to the facility without any reported injuries. However, due to the missed appointment, the resident required further medical evaluation and was subsequently hospitalized for an unrelated inner ear infection. The incident highlighted a failure in communication and supervision protocols, as the resident's care plan clearly indicated the need for supervision during transport and appointments.
Deficiencies in Food Storage and Labeling Practices
Penalty
Summary
The facility failed to maintain proper food storage and labeling practices, as observed during a survey. In the kitchen's walk-in freezer, several food items were found undated, unlabeled, and expired, including a pork chop with freezer burn, a tray of cod, and various other food items such as soup, tortilla shells, and gluten-free pasta. Additionally, the walk-in refrigerator contained items like bacon, margarine spray, and apricot preserves that were either undated or past their use-by dates. The dry goods storage also had issues, with unlabeled white powder and moldy sweet potatoes. Staff member H, responsible for checking food expiration dates, admitted to lapses in monitoring due to a personal absence. She acknowledged that kitchen staff were educated on labeling and dating food but noted issues with labels not being removed during dishwashing. Furthermore, there was confusion about who was responsible for checking refrigerator and freezer temperatures in the resident unit areas, leading to inconsistent temperature monitoring. The facility's policy on refrigerator and freezer management was not adhered to, as evidenced by missing temperature logs for several days in August and September. Kitchen audits conducted by staff member H revealed ongoing issues with expired foods and improper labeling, despite some corrective actions being taken. The facility's policy required daily temperature checks and proper food labeling, but these procedures were not consistently followed, contributing to the deficiencies observed.
Failure to Administer Pain Medication as Ordered
Penalty
Summary
The facility failed to provide pain medication as ordered to relieve chronic pain for a resident, resulting in the resident voicing pain. The incident involved a resident who was prescribed HYDROcodone-Acetaminophen to be administered five times a day for chronic pain. On August 6, 2024, the 1:00 a.m. dose was held, and the 5:00 a.m. dose was not administered as scheduled. The facility's investigation revealed that the staff member responsible for administering the medication forgot to give it. The resident's Medication Administration Record (MAR) did not document the reasons for the missed doses, and the resident reported experiencing significant pain due to the missed medication.
Failure to Maintain a Homelike Environment
Penalty
Summary
The facility failed to provide a comfortable and homelike environment for a resident, as evidenced by a damaged wall and shelf in the resident's room. The resident expressed dissatisfaction with the condition of her room, specifically mentioning a wall that needed repair. An observation revealed a horseshoe-shaped metal rail attached to the resident's bed, which was in contact with the wall, causing a jagged crack and a large hole. Additionally, a red shelf behind the resident's headboard was cracked and broken, creating a large gap. Staff indicated that maintenance was aware of the issue and had informed nursing staff about a month prior that the room needed to be vacated for repairs. However, the maintenance request was not acknowledged or completed in the facility's Maintenance Request Log.
Missing PASARR Document for a Resident
Penalty
Summary
Facility staff failed to ensure a Preadmission Screening and Resident Review (PASARR) document was completed for one of the sampled residents. The resident in question was severely cognitively impaired, with a Brief Interview for Mental Status (BIMS) score of 2, and had been receiving anti-psychotic, anti-anxiety, and anti-depressant medications during the assessment period. The PASARR document was requested on September 11, 2024, but was not provided by the end of the survey. During an interview, a staff member indicated that the facility was unable to locate the PASARR for the resident, who had transferred from a closed facility previously owned by a different company, resulting in a lack of access to the resident's medical records.
Failure to Develop Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop, implement, and document a baseline care plan within 48 hours of admission for one of the sampled residents, identified as resident #57. This deficiency was identified through observation, interview, and record review. Resident #57, who is blind and requires assistance with eating, reported experiencing leg pain and having chronic wounds on her legs since her 20s. Despite these needs, the electronic health record (EHR) showed no documentation of a baseline care plan, which should have been completed by August 1, 2024, following her admission. The absence of this plan meant that the resident's immediate care needs, such as pain management and wound care, were not addressed promptly. During an interview, a staff member revealed that the MDS nurse, who was responsible for initiating the baseline care plan at the time of admission, was no longer employed at the facility, and the plan was not completed. The facility has since changed its process, assigning the responsibility of initiating the baseline care plan to the nurse completing the admission assessment.
Failure to Provide Meaningful Activities for Bedridden Resident
Penalty
Summary
The facility failed to provide an ongoing program of meaningful activities and one-to-one activities for a resident who was mostly bedridden and blind. During an observation and interview, the resident expressed that she was blind and stayed in bed most of the time due to leg pain. She was unable to recall participating in any activities or having any one-to-one visits from the Activities Department. The resident mentioned that she only left her room to go to the dining room for meals and did not remember any staff offering in-room activities. A review of the resident's electronic health record (EHR) revealed that she was admitted to the facility on an unspecified date, but there was no activity assessment completed until several days after the observation. The EHR also showed that the resident had not been invited to or attended any activities, except for a single special event. Additionally, there was no care plan addressing the resident's activity needs. A staff member admitted that the previous Activity Director forgot to conduct the activity assessment, and the current Activity Director was unavailable for an interview.
Failure to Secure Hazardous Area and Assist Resident with Meal Transfers
Penalty
Summary
The facility failed to ensure a safe environment by not keeping a storage room locked, which contained a sharp object resembling a putty knife. This was observed on two separate occasions, despite staff members stating that the door should always be locked to prevent access by wandering residents. Interviews with staff members revealed a lack of consistent practice in securing the storage room, which posed a potential risk for residents who might wander into the area. Additionally, the facility did not adequately assist a resident with significant medical conditions, including an acquired absence of the left leg above the knee and difficulty walking, in transferring from bed to chair for meals. This was necessary to prevent aspiration pneumonia. Despite the care plan indicating the need for a Hoyer lift and two staff members for transfers, the resident was not consistently moved to a chair for meals. Staff interviews indicated that the resident had refused transfers in the past, but there was no clear documentation of these refusals, and the resident expressed a desire to be more comfortable in a chair during meals.
Failure to Implement Comprehensive Care Plan for Oxygen and BPAP Use
Penalty
Summary
The facility failed to implement a comprehensive resident-centered care plan for a resident with oxygenation issues, specifically regarding the use of oxygen and BPAP at bedtime. During an observation, it was noted that the resident's oxygen concentrator was not functioning for the past two weeks, and the resident reported wearing the BPAP mask at night without the concentrator working. Despite the resident's report, staff member B was unaware of any issues with the resident's oxygen equipment, indicating a lack of communication during shift change reports. The resident's care plan, revised in July 2024, did not include goals or interventions for the use of oxygen with BPAP at night, nor did it address any precautions related to oxygen use. The resident's medical history includes obstructive sleep apnea, acute respiratory failure with hypoxia, and morbid obesity with alveolar hypoventilation. The treatment administration record showed an order for BPAP settings with oxygen at bedtime, but the care plan failed to reflect this. The facility's policy on oxygen administration requires reviewing the care plan for special needs and assessing the resident while receiving oxygen therapy, but these steps were not followed. The deficiency was identified through observations and interviews, revealing a gap in the facility's adherence to its own policies and procedures for safe oxygen administration.
Failure to Follow Resident Dietary Preferences
Penalty
Summary
The dietary staff at the facility failed to adhere to the person-centered dietary preferences of a resident, who had clearly communicated his preferences and dislikes to the staff. The resident's meal slip, which included standing orders for coffee, milk, and orange juice with each meal, also listed carrots as a disliked food. Despite this, the resident reported that he frequently had to retrieve his own coffee because it was not provided with his meals, and he continued to receive meals containing carrots. The resident had informed the dietary staff about these issues, but his preferences were still not followed. Interviews with staff members revealed that the dietary staff were aware of the resident's meal slip orders and preferences, but these were sometimes overlooked when staff were rushing. One staff member admitted to preparing the resident's tray too quickly, resulting in the inclusion of carrots despite the resident's expressed dislike. The resident's care plan indicated that he was capable of communicating his needs and that staff were expected to actively listen and validate communication to ensure understanding, yet this was not effectively implemented in practice.
Failure to Provide Transfer Notices to Residents
Penalty
Summary
The facility failed to provide written notice of the reason for facility-initiated transfers to two residents or their representatives. Resident #4 was hospitalized twice in May 2024 for sepsis and a UTI, but the electronic health record (EHR) did not contain the required written notice of the reasons for these transfers. During interviews, staff members indicated that the responsibility for completing the transfer notice lay with someone in administration, and there was no specific form used to notify residents or their representatives of the transfer reasons. Despite requests for the written notices, none were provided by the end of the survey. Similarly, resident #47 was transferred to an acute hospital after a fall and head injury on August 3, 2024, but the facility did not provide a Notice of Transfer/Discharge to the resident or their representative. Staff member E confirmed that the notice had not been provided by the nurse at the time of transfer and reiterated that administration was responsible for issuing such notices. The facility's policy on discharging/transferring residents, last revised in December 2019, requires that a Notice of Discharge/Transfer be provided, explaining the reason for the transfer, the effective date, and information on how to appeal the decision.
Failure to Provide Bed Hold Notices
Penalty
Summary
The facility failed to provide the required bed hold notice to residents or their representatives prior to transfer to a hospital, as evidenced in the cases of two residents. Resident #4 was hospitalized twice in May 2024 for sepsis and a urinary tract infection (UTI), but the electronic health record (EHR) did not contain the necessary written bed hold notice for either hospitalization. Interviews with staff members revealed a lack of clarity regarding responsibility for completing the bed hold notice, with staff member E indicating that someone in administration was responsible, and staff member F unaware of any specific form associated with the bed hold process. Despite a request for resident #4's bed hold notices, none were provided by the end of the survey. Similarly, resident #47 was transferred to an acute hospital after a fall on August 3, 2024, but the facility did not provide a Notice of Bed Hold to the resident or their representative at the time of transfer. Staff member E confirmed that no notice had been provided by the nurse on the day of the transfer, reiterating that administration was responsible for this task. The facility's policy, dated December 19, 2016, stated that residents should be informed of the bed-hold policy upon admission and prior to transfer, with a representative of the business office or designee responsible for providing written information. However, this policy was not followed in the cases of residents #4 and #47.
Neglect Due to Denial of Re-entry After Hospital Discharge
Penalty
Summary
The facility failed to prevent neglect by denying a resident re-entry after he left the hospital against medical advice (AMA) and attempted to return. Despite an administrative directive to allow the resident to rest at the facility for the night, staff members did not follow through, resulting in the resident sitting outside in inclement weather for several hours. The resident, who was weak and had recently been diagnosed with cancer, was left in the rain and cold without a coat, which placed him at high risk of a serious adverse outcome. Staff members were aware of the resident's situation but failed to take appropriate action. Staff member D received a call from the hospital about the resident's return and contacted staff member C for guidance. Despite receiving instructions to allow the resident to stay, staff member D instructed the cab driver to take the resident back to the emergency room. Later, when a passerby and police officers informed the facility staff about the resident sitting outside, the staff continued to deny his entry, claiming he was discharged and needed physician orders to be readmitted. The facility staff's inaction and lack of concern were evident in their interactions with the police and the passerby. The staff did not assess or assist the resident, and no follow-up call was made to a provider for admission orders. The resident was eventually taken to the hospital by police, where he expressed a desire to return to the facility where his belongings were. The facility's failure to act on the administrative directive and their dismissive attitude towards the resident's well-being constituted neglect.
Failure to Timely Report Incidents and Investigation Findings
Penalty
Summary
The facility failed to report a significant event involving a resident who was denied reentry after leaving an acute hospital against medical advice. The resident was left outside the facility in a cab, and when the administration did not respond, the cab driver was instructed to take the resident back to the emergency room. Later, the resident was found sitting on a bench outside the facility, and the police were called. The police took the resident away, and the incident was not reported to the State Survey Agency in the required timeframe. Additionally, the facility did not report the findings of several incidents to the State Survey Agency within the mandated five-day timeframe. These incidents included allegations of falls with injury, resident-to-resident abuse, staff-to-resident abuse, and injuries of unknown origin. The delays in reporting ranged from five to twenty-three days. The facility's policy requires that the administrator or their designee report the results of all investigations within five working days, but this was not adhered to. Interviews with staff revealed that there was a miscommunication and lack of awareness regarding the reporting responsibilities, especially during a change in administration. Staff members admitted to not realizing the findings were not submitted on time and acknowledged their responsibility in the reporting process. The facility's policy outlines the procedure for reporting incidents, but it was not followed, leading to the deficiencies noted in the report.
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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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