Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Brendan House during CMS and state inspections, most recent first.
The facility failed to prevent severe weight loss in a resident with malnutrition and wounds, despite being identified as nutrition at risk and requiring weekly weights. Additionally, another newly admitted resident was not weighed weekly for four weeks as required by policy, with only one weight documented and evidence of poor intake and frailty.
The facility did not ensure that care plans were comprehensive and up-to-date for several residents, omitting key interventions such as cardiac monitoring, BiPAP/CPAP therapy, oxygen and nutritional supplement use, and assistance with ADLs and mobility. Staff relied on unofficial documents instead of the care plan, and required assessments for seatbelt use were not performed due to documentation system issues.
Staff failed to consistently use proper hair restraints during food preparation, with some not fully covering their hair or lacking beard coverings, and there was inconsistent enforcement of hair covering policies. Additionally, a resident received a meal that was not served at an appropriate temperature, with staff lacking knowledge of safe reheating practices and not using thermometers to verify food safety, contrary to facility policy.
The facility did not complete required evaluations or obtain provider orders for four residents who were self-administering medications. Observations included residents independently using inhalers, having unsupervised pills at bedside, and possessing non-facility packaged medications, despite lacking documented assessments or orders for self-administration. Staff interviews and record reviews confirmed these residents were not approved for self-administration according to facility policy.
Two residents experienced compromised dignity and privacy: one was left in a public area with her clothing bottoms down and an uncovered, full catheter bag visible to others, while another was transported to the shower with his back and buttocks exposed to staff and residents. Staff did not take appropriate measures to ensure privacy in either situation.
A resident experienced a severe weight loss over several months, but the provider was not notified as required by facility policy. Although the family was aware, staff failed to communicate the significant decline to the physician, preventing timely intervention.
A resident who experienced distress after being told by a nurse practitioner that he was dying was unable to access grievance forms or file a grievance anonymously. Staff could not locate grievance forms on the units, and facility policies lacked instructions for anonymous submission. The facility's grievance log did not reflect any grievances filed by the resident after the incident.
A resident was placed in a Broda chair that functioned as a physical restraint, preventing independent mobility and causing significant agitation. Staff used the chair to prevent falls without attempting alternative interventions or obtaining a proper assessment or physician order. The facility lacked a restraint policy and did not document the use of the chair as a restraint in the care plan or medical records.
A baseline care plan was not completed within 48 hours of admission for a resident with lung cancer, pain, and type II diabetes. Staff interviews indicated that care plans were not reviewed or properly initiated, and the resident's baseline care plan lacked essential health information such as cognitive status, ADL status, respiratory needs, and dietary requirements.
Two residents did not have their care plans updated to reflect changes in their condition and physician orders. One resident with severe weight loss received one-on-one feeding and nutritional supplements, but these interventions were not added to the care plan. Another resident had an indwelling catheter removed and new orders for bladder scans and as-needed straight catheterization, but the care plan was not revised to reflect these changes.
A resident with severe weight loss and a care plan requiring meal encouragement and one-on-one support did not receive needed assistance during multiple meals. Staff left meal trays covered and out of reach, failed to offer alternatives, and removed untouched trays without providing help, despite the resident expressing hunger and the care plan outlining specific interventions.
A resident admitted with an unstageable pressure injury to the right heel did not receive consistent wound care, including proper cleansing during dressing changes and regular wound assessments. Staff demonstrated inconsistent knowledge of wound care protocols, and documentation of wound measurements and care plan updates was incomplete, contrary to facility policy.
A resident receiving enteral nutrition experienced complications due to improper tube feeding management, including use of an alternate formula without a physician order or notification, inaccurate documentation, and failure to obtain required weights despite recent weight loss. Staff also failed to use appropriate PPE and did not follow facility policy for handling feeding equipment and monitoring.
A resident with terminal lung cancer was observed using oxygen therapy without a physician's order in place. Staff confirmed that it is their responsibility to obtain such orders, and facility policy requires a provider order before initiating oxygen therapy. However, review of records showed no order for oxygen use during the relevant period.
Staff did not consistently follow infection prevention and control protocols during wound care, suctioning, and tube feeding for several residents. Observations included failure to perform hand hygiene, improper glove changes, and not wearing gowns as required by Enhanced Barrier Precautions. These lapses occurred despite staff awareness of facility policies and recent training.
Two residents did not receive proper assessment or administration of pneumococcal vaccines as per CDC guidelines. One had consented to all immunizations but did not receive the recommended follow-up vaccine, while another had no vaccination history or consent documented and was not asked about vaccines on admission. Staff were unclear on current vaccine recommendations, and facility policy was not consistently followed.
Facility staff failed to comply with hair restraint protocols during food preparation, with observations showing improper or absent use of hairnets and beard nets. Despite education efforts, staff continued to not fully cover their hair, increasing the risk of contamination.
Two residents experienced significant and severe weight loss without proper notification to their physicians or families. One resident lost 5.09% of their weight in a month, while another lost 17% over six months. Despite facility policy requiring notification of such changes, no documentation was found to indicate that the necessary parties were informed.
The facility failed to ensure proper hand hygiene during meal service and a blood draw, with staff members not washing hands or changing gloves between resident interactions. Laboratory personnel also neglected infection control practices during a blood draw in the dining room. These actions violated the facility's hand hygiene policy and CDC guidelines, putting residents at risk for infection.
A resident's privacy was compromised during a blood draw conducted in an open dining room, with other residents present. The resident was confused and not given a choice to move to a private area. Laboratory personnel did not use proper infection control practices, as one was barehanded while handling supplies and blood vials. The resident expressed distress and confusion about the procedure and personnel involved.
Two residents experienced issues with meal provision, leading to severe weight loss for one. A resident with CHF faced delays in receiving breakfast, while another on a puree diet refused meals, resulting in significant weight loss. Staff disorganization and lack of dietary preference discussions contributed to these deficiencies.
Two residents in the facility experienced tube feeding administration errors, with one resident receiving the wrong formula and another receiving an additional bolus. Staff acknowledged the errors and attributed them to the similarity in appearance of supplies, despite labeling efforts. There was a lack of recent staff training on tube feeding procedures.
A facility failed to report an alleged abuse incident involving a resident within the required 24-hour period. The incident was reported two days late, preventing timely protective measures. A staff member noted the resident's concern about rough handling but did not report it immediately. Facility policy requires reporting such incidents within 24 hours, but this was not adhered to, resulting in a deficiency.
A resident reported being injured by a staff member during care, and the accused staff member was reassigned to other residents instead of being removed from care duties. The facility's policy requires immediate protection for residents, including suspending the accused employee, but this was not implemented, leading to a deficiency in resident protection.
Failure to Prevent Severe Weight Loss and Incomplete Weekly Weights for New Admission
Penalty
Summary
The facility failed to prevent severe weight loss in one resident and did not complete required weekly weights for a new admission. One resident experienced a 9% weight loss in one month, dropping from 132 lbs. to 120 lbs., despite being identified as nutrition at risk (NAR) and having a diagnosis of malnutrition and wounds. Staff interviews revealed that the resident was receiving supplements and was under supervision during meals, but there were issues with meal assistance, care plan updates, and consistent monitoring. The resident had a history of progressing dementia, difficulty swallowing, and required speech therapy, with documentation indicating that weekly weights were ordered but not consistently obtained. Another resident, who appeared thin and frail and was receiving oxygen, was not weighed weekly for four weeks after admission as required by facility policy. The resident reported a decreased appetite and was provided with nutritional supplements, but did not always consume them. Review of the medical record showed only one documented weight during the initial four-week period, contrary to the facility's policy that mandates weekly weights for new admissions to establish a baseline.
Failure to Implement and Update Comprehensive Care Plans for Multiple Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that addressed all identified needs for several residents. For one resident with a cardiac pacemaker, the care plan did not include any mention of cardiac monitoring, despite documentation in hospital records and nursing notes indicating the presence and management of a pacemaker and related monitoring equipment. Another resident who used BiPAP therapy for respiratory issues and experienced increased nighttime anxiety did not have interventions listed for BiPAP/CPAP therapy in the care plan, nor was the presence of a nighttime sitter documented, even though the resident continued to employ a private caregiver overnight. Additionally, a resident with terminal lung cancer who used continuous oxygen and received nutritional supplements did not have physician orders for these interventions, and the care plan lacked focus, goals, or interventions for oxygen or supplement use. Observations confirmed the use of oxygen and the presence of nutritional supplements in the resident's room. Another resident who required assistance with activities of daily living (ADLs) and mobility, and who was observed propelling himself in a wheelchair, also did not have these needs addressed in the care plan. Staff interviews revealed reliance on separate paper documents rather than the official care plan for guidance on resident care needs. The facility also failed to implement care planned assessments for seatbelt use for a resident in a wheelchair. Although the care plan specified quarterly assessments to ensure the resident could unbuckle the seatbelt and that it was functioning for positioning, these assessments had not been completed since a change in the electronic health record system, due to the absence of a template. Staff interviews confirmed that physician orders for seatbelt use were obtained only once and that there was no specific facility policy for seatbelt use.
Failure to Ensure Food Safety and Proper Hygiene During Meal Preparation and Service
Penalty
Summary
The facility failed to ensure proper food safety and hygiene practices in the kitchen and during meal service. Multiple staff members were observed not wearing appropriate hair restraints while preparing food, including hair nets that did not fully cover hair, lack of beard coverings, and staff entering the kitchen without any hair covering. Staff interviews revealed a lack of awareness and inconsistent enforcement of the facility's hair covering policy, with some staff unaware of the requirements and others acknowledging difficulty in monitoring compliance due to high turnover. Signage reminding staff to wear hair coverings had been removed, and the kitchen doors were routinely propped open, further compromising food safety standards. Additionally, the facility did not provide food at an appetizing or safe temperature for a resident. Observations showed that a resident received breakfast that had been left in the room and later reheated in a microwave, resulting in food that was cold in some areas and described as unappetizing by the resident. Staff responsible for reheating food were unaware of required food temperatures and timelines for safe consumption, and did not use thermometers to check food temperature after reheating. Facility policy required reheated food to reach 165 degrees for 15 seconds, but this standard was not followed. Some staff stated that reheating food was not standard practice and that trays should be refrigerated or replaced if not eaten promptly, but this was not consistently implemented or communicated.
Failure to Assess and Obtain Orders for Resident Self-Administration of Medications
Penalty
Summary
The facility failed to obtain evaluations and provider orders for residents to self-administer medications for four residents. Observations revealed that one resident was using a nebulizer independently without a documented self-administration evaluation or provider order, despite having an active medication order for inhaled treatment. Another resident was observed with a cup of pills left at the bedside, taking medications at his own pace due to swallowing issues, but without an assessment or physician order for self-administration. A third resident with severe cognitive impairment, as indicated by a BIMS score of 7, was found with unsupervised medications at her table and no documented assessment for safe self-administration. The fourth resident brought a bag of assorted, non-facility packaged pills to the nurse, and staff were unaware of their origin; this resident also lacked a provider order for self-administration. Interviews with staff confirmed that the required interdisciplinary team evaluations and provider orders for self-administration were not present for these residents. Facility records and a list of approved residents for self-administration did not include the four residents in question. Documentation review further showed that the necessary assessments and orders were missing from both the electronic health records and paper charts for these individuals.
Failure to Maintain Resident Dignity and Privacy During Care Activities
Penalty
Summary
The facility failed to maintain resident dignity and privacy in two separate incidents. In the first case, a resident was observed napping in the dining room in a wheelchair, with her clothing bottoms pulled down below her knees, exposing her catheter and a full catheter bag without a privacy cover. The resident was positioned facing the dining room and unit entrance, with other residents and staff present, and staff did not address the visible catheter bag or the resident's state of undress. Staff later reported attempting to encourage the resident to put her pants on, but the issue persisted until the resident was eventually taken to her room and assisted in dressing. In the second incident, a resident was assisted by staff onto a shower chair while wearing a hospital gown, leaving his back and buttocks exposed. The staff member then transported the resident out of his room and past the dining area, where multiple residents and staff could see him, without making any attempt to cover the exposed areas. The staff member later acknowledged not checking for exposure, and the resident reported feeling upset and embarrassed by the incident. Facility policy reviewed confirms residents' rights to privacy.
Failure to Notify Provider of Significant Weight Loss
Penalty
Summary
A resident experienced a significant and severe weight loss, losing 60 pounds over six months and 26 pounds in the last month, as documented in the electronic health record. Despite this marked decline, the medical provider was not notified of the weight loss, which prevented the physician from having the opportunity to plan or implement interventions. Interviews with staff revealed that while the resident's family was aware of the weight loss, several staff members were unaware of the extent of the decline, and the responsible staff member admitted to not notifying the physician as required. The facility's policy required that all significant changes in weight be reported to the resident's provider, specifically noting thresholds of 5% in 30 days or 10% in 180 days. The resident had been admitted to the Nutrition at Risk Committee, and a note in the record indicated that the care manager was to notify the provider of the weight loss. However, this notification did not occur, as confirmed by staff interviews and record review.
Failure to Provide Access to Grievance Forms and Anonymous Submission
Penalty
Summary
The facility failed to provide residents with access to grievance forms and the opportunity to file grievances anonymously, as required by regulation. One resident reported being told by a nurse practitioner that he was dying and that his kidney function was severely compromised, which was later contradicted by hospital staff. The resident expressed anger and distress over the incident and attempted to seek answers from facility staff but was unable to obtain any. He stated he was unaware of the existence of grievance forms and had not seen any available in the facility. The resident also indicated that his wife would have preferred to file a grievance anonymously if given the opportunity. Observations and staff interviews revealed that grievance forms and boxes were not present in common areas or on the units, and staff were unable to locate the forms when requested. Some staff members were unsure of the process for handling grievances or how residents could file them anonymously. The facility's policy and resident rights documents did not provide instructions for anonymous grievance submission. A review of the facility's grievance log showed no record of grievances filed by the resident, including after he returned from the hospital and voiced his concerns.
Failure to Prevent Use of Physical Restraint Without Assessment or Alternatives
Penalty
Summary
A resident was observed repeatedly confined to a Broda chair, which was reclined at a 45-degree angle with the footrest elevated, preventing the resident's feet from reaching the floor and making it impossible for the resident to exit the chair independently. The resident was visibly agitated, yelling to be let out, attempting to climb over the arm of the chair, and throwing items onto the floor. Staff interviews revealed that the Broda chair was used to prevent falls, as the resident had a history of falling from a standard wheelchair. However, there was no evidence that alternative interventions for fall prevention were attempted prior to the use of the Broda chair. Review of the resident's care plan and medical records showed no documentation of alternative fall interventions, no assessment by physical therapy for the use of the Broda chair, and no physician order for a restraint. The facility did not have a restraint policy or procedure, as it identified itself as a restraint-free facility. Staff confirmed that the use of the Broda chair was not based on a formal assessment or recommendation, and the resident's agitation was attributed to being confined in the chair.
Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to complete a baseline care plan within 48 hours of admission for one resident, as required. Staff interviews revealed that one staff member did not review or look at the resident's baseline care plan, while another staff member, who oversees care planning, stated that baseline care plans are supposed to be completed within 48 hours and that nursing staff are responsible for initiating and updating them. Record review showed that the baseline care plan for the resident was not filled out and did not include essential information such as cognitive status, ADL status, bowel or bladder status, transfer status, respiratory status (including oxygen use), communication status, mobility device use, or type of diet. The resident had diagnoses of lung cancer, pain, and type II diabetes mellitus. The facility's policy requires that care plans be initiated upon admission and describe the services necessary to attain or maintain the resident's highest practicable well-being.
Failure to Update Care Plans Following Changes in Resident Condition and Orders
Penalty
Summary
The facility failed to update care plans in response to changes in resident conditions and physician orders for two residents. For one resident experiencing severe weight loss, documentation provided to the physician indicated poor appetite, use of nutritional supplements, and staff providing one-on-one assistance with meals. However, the resident's care plan was not updated to reflect the use of one-on-one feeding or nutritional supplements, despite staff interviews confirming these interventions were being provided and the resident was being monitored for nutrition risk due to weight loss. For another resident, physician orders indicated the removal of an indwelling catheter and new orders for bladder scans and as-needed straight catheterization following a voiding trial. The care plan for this resident continued to list risk for infection due to the indwelling catheter and was not updated to include the catheter removal or the new interventions. Staff interviews confirmed that care plans were expected to be updated as resident needs and physician orders changed, and facility policy required care plans to be reviewed and revised accordingly.
Failure to Provide Meal Assistance to Resident Requiring Support
Penalty
Summary
Facility staff failed to provide necessary assistance with meals to a resident identified as requiring encouragement and one-on-one support for eating. Multiple observations showed the resident's meal trays were left covered and out of reach, both while the resident was in bed and seated in a Broda chair. On several occasions, staff members were present but did not offer assistance, encouragement, or alternatives before removing untouched meal trays. Interviews with staff revealed inconsistent understanding of the resident's needs, with some staff stating the resident could feed himself, while others acknowledged he required encouragement and occasional one-on-one help. Staff also cited the resident's comfort care status as a reason for not assisting with meals, despite the care plan indicating interventions such as encouragement to eat and offering substitutes or supplements if intake was low. The resident was noted to have severe weight loss and was being monitored in nutrition at risk meetings. The care plan specifically outlined goals and interventions to address nutritional needs, including ensuring the resident consumed more than 50% of meals and providing alternatives if intake was insufficient. Despite these documented needs and interventions, staff did not consistently implement the care plan, resulting in the resident not receiving necessary care and services related to meal assistance.
Failure to Provide Comprehensive Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide appropriate care and services to prevent the worsening of an unstageable pressure injury for one resident admitted with a right heel wound. During a dressing change, staff did not cleanse the wound before applying a new dressing, and there were no clear wound care orders for cleansing. Staff interviews revealed inconsistent knowledge of wound care protocols, including the use of offloading boots, air mattresses, and repositioning. The resident was identified as being at nutritional risk, and recommendations for wound healing supplements were made, but documentation of consistent interventions was lacking. Review of the resident's records showed incomplete and inconsistent wound assessments, with missing weekly measurements and documentation. The care plan did not reflect any new interventions or changes for wound management since admission, and time frames for monitoring and measuring the wound were not specified. Facility policy required weekly wound assessments and photographs, but these were not consistently documented. The lack of comprehensive wound care documentation and failure to follow established protocols contributed to the deficiency.
Failure to Ensure Proper Tube Feeding Management and Documentation
Penalty
Summary
The facility failed to ensure proper management of tube feeding for a resident, resulting in complications and failure to maintain the resident's weight. During observation, a resident was found with leaking tube feeding, and staff responded without donning appropriate PPE beyond gloves. The staff cleaned the leaked feeding and adjusted the tube, but the process revealed issues with the administration and handling of the feeding equipment. Additionally, the suction container was improperly handled and disposed of in the sink, then returned to the bedside table. Further review showed that the prescribed tube feeding formula, Isosource 1.5, was unavailable for two days, and an alternate formula, Fibersource, was used without a new physician order or notification to the physician. The change in formula was not documented in the resident's orders, and the TAR inaccurately reflected that Isosource was administered. Daily weights, ordered to monitor the resident's status, were not documented as required, despite a recent significant weight loss. The facility's policy required weights to be obtained three times a week, but this was not followed.
Oxygen Therapy Administered Without Physician Order
Penalty
Summary
Licensed nursing staff failed to ensure that a physician's order was in place for a resident's oxygen use. During observation, a resident with a diagnosis of metastatic lung cancer was found lying in bed using oxygen via nasal cannula, with the concentrator set to 1.5 liters. The resident reported using oxygen continuously due to his terminal condition. Staff interviews confirmed that nursing staff are responsible for obtaining physician orders for oxygen therapy and are expected to notify the physician and secure the necessary order when oxygen is needed. However, a review of the resident's physician orders for the relevant period showed no order for oxygen use, despite facility policy requiring a provider order for initiation of oxygen therapy.
Failure to Adhere to Infection Control Practices During Resident Care
Penalty
Summary
Staff failed to adhere to infection prevention and control standards during wound care, suctioning, and tube feeding for multiple residents. In one instance, a staff member performed a dressing change on a resident's right heel without changing gloves or performing hand hygiene between removing the soiled dressing and applying the clean one. The wound was not cleansed prior to dressing, and the staff member did not wear a gown as required by Enhanced Barrier Precautions (EBP). The staff member also left the resident's room without removing gloves, contrary to facility policy. Another resident on EBP had tube feeding and suctioning performed by staff who only wore gloves, omitting the required gown. Staff cleaned up leaked tube feeding and handled suction equipment without donning gowns, and did not follow proper procedures for disposing of suction contents. Observations also revealed that staff did not perform hand hygiene before or after care, or after removing personal protective equipment, as required by facility policy. A third resident receiving wound care had staff who donned PPE but failed to change gloves or perform hand hygiene after touching potentially contaminated surfaces, such as the door and bed linens. Supplies were handled and placed on various surfaces without proper glove changes or hand hygiene. After completing care, the staff member disposed of trash without gloves and did not perform hand hygiene before handling medication cards. Interviews confirmed that staff were aware of infection control policies but did not consistently follow them during care.
Failure to Ensure Pneumococcal Vaccination Assessment and Administration
Penalty
Summary
The facility failed to ensure that residents received, or had the opportunity to receive, the pneumococcal vaccine series as recommended. For one resident, documentation showed that consent for all immunizations, including pneumococcal, was provided by the resident's representative, and the resident had previously received the pneumococcal 23 vaccine. However, there was no evidence that the facility assessed or administered the additional pneumococcal vaccines (pneumococcal 20 or 21) as recommended by the CDC for individuals who have only received the pneumococcal 23 vaccine and for whom more than one year has passed since administration. For another resident, there was no documentation of vaccination history or consent in the electronic medical record, and the resident reported not being asked about vaccinations upon admission. The facility's policy stated that CDC recommendations for pneumococcal immunization would be followed, but staff interviews revealed a lack of knowledge regarding current vaccine recommendations and uncertainty about why vaccinations were missed. These findings indicate that the facility did not consistently follow its own policy or CDC guidelines regarding pneumococcal vaccination assessment and administration.
Non-Compliance with Hair Restraint Protocols in Food Preparation
Penalty
Summary
The facility staff failed to adhere to proper hair restraint protocols during food preparation, as observed on multiple occasions. Staff members were seen with hairnets that did not fully cover their hair, including bangs and hair below buns, while others had no beard nets despite having full beards. This non-compliance with the facility's hair restraint policy was noted during food preparation activities, increasing the risk of hair contamination in food served to residents. Interviews with staff confirmed the lack of compliance with the facility's hair restraint policy, which requires all hair to be covered and beards longer than half an inch to be covered in the kitchen or service areas. Despite education being provided to the kitchen staff, further observations revealed continued non-compliance, with staff members either not wearing hairnets or wearing them improperly, and external personnel entering the kitchen without hair restraints.
Failure to Notify Physician and Family of Significant Weight Loss
Penalty
Summary
The facility failed to notify the physician and family of significant and severe weight loss in two residents. Resident #19 experienced a 5.09% weight loss in one month, which is considered significant. Despite this, there were no notifications to the physician, and the last dietician note was dated over a month before the weight loss was recorded. Staff interviews revealed that the resident required assistance with feeding, including cueing and redirection, and was receiving a nutritional supplement with meals. However, there was no documentation of further interventions or notifications to the physician or family regarding the weight loss. Resident #52 experienced a 17% weight loss over six months, classified as severe. Similar to Resident #19, there were no notifications to the physician or family documented. The last record entry was from February, and although the resident was discussed in Nutrition at Risk meetings, the physicians were not involved in these discussions. The facility's policy requires that significant weight changes be reported to the resident's provider and responsible party, but this was not adhered to in these cases.
Inadequate Hand Hygiene and Infection Control Practices
Penalty
Summary
The facility failed to ensure proper hand hygiene practices were followed by staff during meal service in both common dining areas and resident rooms. Multiple staff members, including staff members E, U, Q, F, and G, were observed not performing hand hygiene after direct contact with residents or their environments. Staff member E, in particular, was noted for repeatedly failing to wash hands or change gloves between assisting different residents, handling food items, and touching various surfaces. This lack of hand hygiene was observed during the delivery and setup of meal trays for several residents, including residents #16, #25, #46, #52, #61, and #70. Additionally, during a blood draw for resident #259, laboratory personnel did not adhere to infection control practices. NF1 and NF2 conducted a blood draw in the dining room without using a barrier between the resident's arm and the pillow, and NF1 handled used supplies without gloves. The laboratory staff did not demonstrate awareness of specific infection control training, although they reportedly followed precaution signs on resident doors. The facility's hand hygiene policy, IPC104, and CDC guidelines emphasize the importance of performing hand hygiene before and after patient contact and after glove removal. However, observations revealed that these protocols were not consistently followed, putting residents at risk for infection. Interviews with staff members A, Z, and FF highlighted a lack of adherence to infection control practices and uncertainty about the training received by laboratory staff.
Privacy Breach During Blood Draw in Dining Room
Penalty
Summary
The facility failed to ensure privacy during a blood draw for a resident, which was conducted in an open dining room. The resident was seated at a table with a tablemate and other residents present when laboratory personnel approached and informed her of a STAT order for a blood draw. Despite the resident's confusion and questioning, the personnel proceeded with the blood draw in the dining room without providing a privacy barrier. The resident's tablemate and another resident observed the procedure, compromising the resident's privacy. Additionally, the laboratory personnel did not adhere to proper infection control practices. One staff member was barehanded while handling used supplies and blood vials, which were placed in open plastic bags on a mobile cart. The resident expressed confusion and distress during a subsequent interview, indicating a lack of understanding about the procedure and the personnel involved. The facility's staff member stated that it was typically up to the resident to decide whether to have procedures done in a common area, but there was no indication that the resident was given this choice or that her comfort was assessed.
Failure to Provide Therapeutic Diets Leads to Severe Weight Loss
Penalty
Summary
The facility failed to provide therapeutic diets to optimize the nutritional status for two residents, leading to severe weight loss for one of them. Resident #25, who has a diagnosis of Congestive Heart Failure and ongoing lower extremity edema, experienced issues with meal delivery and consumption. On the morning of 8/27/24, Resident #25 was not served breakfast in a timely manner, despite multiple requests and the presence of his call light. His breakfast tray remained untouched in the dining room while staff members were disorganized and failed to address his needs promptly. Eventually, Resident #25 only received two pieces of toast for breakfast at around 10:30 a.m., with no other food offered. Resident #41, who was on a puree diet, refused to eat the meals provided, opting instead for cookies and snacks brought by his wife. Despite being on a puree diet, his meal ticket indicated a soft diet, and he expressed dissatisfaction with the texture of the food. Over a three-month period, Resident #41 experienced a severe weight loss of 18.13%. Staff member N had changed his diet to include Benecal protein shakes per his preference but had not discussed his food preferences in detail to understand why he was not eating the provided meals.
Tube Feeding Administration Errors
Penalty
Summary
The facility failed to ensure that residents received tube feedings as ordered, resulting in deficiencies for two residents. Resident #77 was observed with a tube feeding pump that was alarming due to a flow clog, and the pump door was found to be open, preventing proper flow. Staff member Y admitted to not realizing the impact of the open pump door, which led to the alarm. Additionally, resident #77 was given the wrong tube feeding formula, Fibersource HN instead of the prescribed Isosource 1.5, as noted in the resident's electronic health record. Resident #36 also experienced issues with tube feeding administration. The resident received an additional bolus of Fibersource HN and was later given the wrong tube feeding formula, Isosource 1.5 instead of the prescribed Fibersource HN. These errors were documented in the resident's electronic health record, with no adverse effects observed. Staff member Z mentioned that the resident's family was being trained on tube feeding administration, but there had been no recent staff training on tube feeding procedures. The facility identified tube feeding errors starting on 8/8/24 and began discussing corrective options. However, the report does not detail specific actions taken to prevent future errors. Staff member FF acknowledged that incorrect tube feedings were treated as medication errors, and there was a need for additional training due to the recurring errors. The facility's management attributed some errors to the similarity in appearance of the supplies, despite labeling efforts to differentiate them.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an alleged incident of abuse involving a resident within the required 24-hour reporting period. The incident occurred on January 17, 2024, but was not reported to the State Survey Agency until January 19, 2024. This delay in reporting was attributed to a staff member's inaction, which prevented the facility from taking timely measures to ensure the resident's protection. The facility's policy mandates that all staff members are responsible for reporting abuse, and it is the responsibility of the Director of Nursing and Administrator to ensure compliance with this policy. The incident involved a resident who reported to a staff member on January 19, 2024, that she wanted to speak about possible rough handling. The staff member noted this concern but did not report it immediately. During an interview, a staff member confirmed that administration was available on weekends to report incidents, and nurses were mandatory reporters. The facility's policy requires that any incidents of alleged abuse or injuries of unknown origin be reported to the Department of Public Health and Human Quality Assurance Division Certification Bureau within 24 hours after discovery. However, this procedure was not followed in this case, leading to the deficiency.
Failure to Protect Resident During Abuse Investigation
Penalty
Summary
The facility failed to protect a vulnerable resident from potential harm during an abuse investigation. A resident reported being injured by a staff member during a brief change and described the staff as verbally spiteful. The incident was reported to another staff member, who added it to the alert charting. Despite the report, the accused staff member was reassigned to care for other residents, which increased the risk of harm to other vulnerable residents. Interviews with staff and residents were conducted, and a follow-up investigation report was completed. The facility's policy on abuse prevention and reporting requires immediate protection for residents involved in incidents, including the potential suspension of the accused employee. However, interviews with staff revealed a lack of awareness and implementation of this policy. The facility's practice was to reassign the accused staff member rather than remove them from resident care, contrary to the policy. This oversight led to a deficiency in protecting residents during the investigation process.
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Illustrative
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Kalispell
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Kalispell Rehabilitation And Nursing Llc | 0.3 mi | — | 40 | 0 |
| Immanuel Skilled Care Center | 0.5 mi | — | 11 | 0 |
| Montana Veterans Home N H | 12.3 mi | — | 0 | 0 |
| Whitefish Care And Rehabilitation | 13.2 mi | — | 33 | 0 |
| Polson Health & Rehabilitation Center | 37.5 mi | — | 6 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.