Madison Valley Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Ennis, Montana.
- Location
- 211 N Main St, Ennis, Montana 59729
- CMS Provider Number
- 275136
- Inspections on file
- 16
- Latest survey
- May 20, 2026
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Madison Valley Manor during CMS and state inspections, most recent first.
Surveyors identified multiple instances of undated, unlabeled, and expired food items in storage areas and refrigerators, as well as improper storage of open food containers. Staff interviews confirmed inconsistent food inventory audits and lack of adherence to facility policy on food labeling. Additionally, a dusty oscillating fan was used to dry clean dishes without a set cleaning schedule, and a kitchen floor drain was found to be cracked, unsealed, and in disrepair for an extended period, with staff unable to secure timely repairs.
A kitchen freezer was not properly maintained, with the bottom shelves marked 'Do Not Use' due to issues causing freezer burn and a faulty door seal that failed to keep food frozen. Staff reported the freezer was scheduled for replacement but this was delayed, and food was sometimes discarded when staff forgot not to use the affected shelves.
The facility did not complete or document required assessments before using bed rails and a scoop mattress as restraints or assistive devices for three residents. In each case, documentation was missing or incomplete regarding whether the devices limited freedom of movement, if risks and benefits were discussed, and whether residents could remove the devices independently. Ongoing monitoring of these devices was also not consistently performed or documented.
A resident's representative was not notified after the resident sustained a fall with injury, was diagnosed with a UTI, and was started on antibiotics. Nursing notes documented the incidents and treatment changes, but there was no evidence that the representative was informed, contrary to facility policy.
The facility did not implement or make accessible a comprehensive grievance process, failing to post required information, provide accessible grievance forms, or offer a secure method for anonymous submissions. A resident was unaware of how to file a grievance or do so anonymously, and staff confirmed the lack of accessible forms and secure receptacle, contrary to facility policy.
Two residents were inaccurately assessed, with assistive devices such as a scoop mattress and bed rails incorrectly coded as restraints on their MDS assessments. Both residents were able to move and get out of bed independently, and staff confirmed the devices did not restrict their mobility, yet the documentation did not reflect this.
A resident with left-sided paralysis and limited hand mobility was found with bed rails in the up position and was unable to lower them independently. Staff and documentation failed to recognize and record the bed rails as a restraint, and the assessment did not address that the resident could not remove the rails or that they limited movement, contrary to facility policy.
The facility did not ensure competent nursing staff were available to provide timely medication administration and meet residents' needs. A resident and others reported issues with a travel nurse's attitude and care timeliness, and medication records showed that a resident received several medications hours after the scheduled time on multiple occasions, outside the facility's allowed window. The facility relied heavily on travel nurses, and some did not seek help when running late, resulting in late medication passes.
A hospice resident with advanced disease experienced inconsistent and delayed pain management, as staff often waited to administer stronger pain relief like morphine until after less effective medications were tried, despite ongoing pain. Documentation of pain assessments and follow-up was incomplete, and family members had to advocate for appropriate pain control, resulting in unnecessary discomfort.
The facility did not provide infection prevention and control training to temporary agency staff, as revealed through interviews and observations. A traveling CNA and two other traveling employees reported not receiving such training during their orientation. Observations showed improper hand hygiene practices, and there was no documentation of infection control training for these staff members.
A staff member failed to follow standard precautions during personal care of a resident by not sanitizing hands before donning gloves and not changing gloves between dirty and clean tasks. The staff member acknowledged the oversight, which was against the facility's policy requiring hand hygiene and glove changes to prevent cross-contamination.
The facility failed to ensure accurate MDS coding for diagnoses and restraints. One resident's dementia diagnosis was not updated in the MDS, and three other residents had discrepancies in the documentation of bed rails and alarms. Staff interviews confirmed the lack of a reliable process for updating diagnoses and inconsistencies in MDS coding.
The facility failed to update care plans for two residents, one regarding discontinued blood glucose monitoring and wheelchair use, and another regarding the removal of bed rails. Staff interviews and observations confirmed the discrepancies.
The facility failed to implement bed rails and update the care plan for a resident. Observations showed the absence of bed rails despite a physician's order and care plan indicating their use. Staff interviews revealed confusion about the bed rails' presence and lack of an order to discontinue their use.
Deficient Food Storage, Labeling, and Kitchen Sanitation Practices
Penalty
Summary
The facility failed to ensure proper food storage and labeling practices, as evidenced by multiple observations of undated, unlabeled, and expired food items in the dry storage area, walk-in refrigerator, and resident refrigerator. Items such as open bags of pasta, cereal, and chips, as well as expired Jello mix and undated containers of sauces and dairy products, were found. Staff interviews revealed that food inventory audits were intended to be performed monthly, but expired and improperly labeled items were still present. Facility policy required all foods to be covered, labeled, and dated, but this was not consistently followed. Additionally, the facility did not maintain a clean kitchen environment. An oscillating fan, used to blow air on racks of drying dishes, was observed to have visible gray dust on its spokes and back, with no set cleaning schedule in place. Staff acknowledged the need for cleaning but indicated it was only done when noticed and as time allowed. The fan continued to be used in this condition, posing a risk of dust contaminating clean dishes. The kitchen floor drain was also found to be in poor condition, with a damp towel covering it at times and visible cracks and openings around the drain. Staff interviews and documentation confirmed that the drain had been in disrepair for over a year, with a known crack in the pipe and ongoing difficulties in securing repairs. The area around the drain was unsealed, and odors were sometimes noticed, further indicating a lack of proper maintenance and sanitation in the kitchen environment.
Failure to Maintain Freezer in Safe Operating Condition
Penalty
Summary
The facility failed to ensure that one of the kitchen freezers was adequately maintained and in safe operating condition. During observation, the bottom shelves of the kitchen entryway freezer were marked with cardboard signs stating 'Do Not Use,' yet food items were stored on all other shelves. Staff interviews revealed that the freezer was scheduled for replacement but this had been delayed due to planned kitchen renovations. Staff also reported that the bottom shelf caused freezer burn to food items, leading to food being discarded when staff forgot not to use those shelves. Additionally, there were issues with the freezer door seal, which failed to maintain the frozen state of foods placed on the bottom shelves. Review of the FDA Food Code confirmed that equipment components such as doors and seals should be kept intact and adjusted according to manufacturer specifications, and that corrective action should be taken if equipment fails to maintain proper storage conditions.
Failure to Assess and Document Use of Restraints and Assistive Devices
Penalty
Summary
The facility failed to perform and document complete resident assessments prior to the use of physical restraints or assistive devices that could be considered restraints for several residents. In one case, a resident with left-sided paralysis and limited hand mobility had upper bed rails in place, which he could not lower independently. Staff and the resident indicated the bed rails were used to prevent falls and assist with mobility, but documentation did not show whether the bed rails met the criteria for a restraint or if risks and benefits were discussed with the resident or representative. The assessments also failed to indicate if the resident could remove the bed rails independently, despite staff statements that the rails restricted his ability to get out of bed. Another resident was observed using a scoop mattress, which she stated did not restrict her movement and was used to assist with transfers and positioning due to poor core control. However, the facility did not complete or document an assessment prior to the initial use of the scoop mattress, nor did they provide ongoing monitoring of its use. The evaluation on file did not address whether the scoop mattress limited the resident's freedom of movement, and there was inconsistency in the documentation regarding whether it was considered a restraint. A third resident was observed with bed rails in the up position, which she stated helped prevent her from falling out of bed. Staff confirmed the bed rails were used for safety, and the resident was able to get out of bed independently. However, there was a lack of documented Assistive Device/Restraint Evaluations for an extended period, indicating a failure to perform ongoing monitoring of the use of bed rails as required. The facility's policy defined restraints based on the resident's ability to remove the device and its impact on freedom of movement, but the required assessments and documentation were incomplete or missing for the residents involved.
Failure to Notify Resident Representative of Fall, UTI, and Antibiotic Initiation
Penalty
Summary
The facility failed to notify a resident's representative regarding significant changes in the resident's condition and treatment. Specifically, the representative was not informed when the resident experienced an unwitnessed fall resulting in a skin tear and bruising on the right hand, wrist, and forearm. Nursing progress notes documented the fall and resulting injuries but did not indicate that the resident's representative was notified of the incident, as required by facility policy. Additionally, the facility did not notify the representative when the resident was diagnosed with a urinary tract infection (UTI) and subsequently started on antibiotics. Although staff believed the representative was aware that a urine specimen was being collected, there was no documentation or confirmation that the representative was informed of the UTI diagnosis or the initiation of antibiotic treatment. The facility's policy requires notification of family or representatives in the event of accidents resulting in injury or significant changes in treatment, which was not followed in these instances.
Failure to Provide Accessible Grievance Process and Information
Penalty
Summary
The facility failed to develop, implement, and operationalize a comprehensive grievance policy and procedure, as required. During a walk-through, it was observed that there was no documentation on how residents could file a grievance posted in common areas, and grievance forms were only available in a single location next to the nurse's station, which was partially obstructed by a chair. There was no posting of the name or contact information for the grievance official, and no secure receptacle or written information was available for residents to file grievances anonymously. A review of facility policy indicated that such information should be provided upon admission and posted on the resident bulletin board, but these requirements were not met. Interviews revealed that a resident was unaware of the location of grievance forms or the option to file grievances anonymously, expressing a desire for a receptacle to submit anonymous grievances. A staff member confirmed the limited and inaccessible placement of grievance forms and acknowledged the absence of a secure receptacle for anonymous submissions. The facility's own policy and resident handbook outlined procedures for filing grievances, including anonymous submissions and the provision of contact information for the grievance officer, but these were not operationalized or made accessible to residents as required.
Incorrect Coding of Assistive Devices as Restraints
Penalty
Summary
The facility failed to ensure that assistive devices were accurately assessed and not incorrectly coded as restraints for two residents. In the first case, a resident who used a scoop mattress due to poor core control demonstrated the ability to turn, sit up, and get out of bed independently. Both the resident and staff confirmed that the scoop mattress did not restrict movement, and the resident's evaluation noted it was not used as a restraint. However, the Minimum Data Set (MDS) assessments inaccurately coded the scoop mattress as a restraint, despite evidence to the contrary. In the second case, another resident used bed rails as a mobility aid to prevent rolling out of bed and was able to sit and stand independently. Staff confirmed that the bed rails did not limit the resident's mobility or ability to get out of bed. Despite this, the resident's MDS assessments consistently coded the bed rails as being used daily, which was not accurate since they did not function as restraints. These inaccuracies in assessment and documentation led to the deficiency.
Failure to Assess and Document Bed Rail Use as a Restraint
Penalty
Summary
The facility failed to perform and document a complete assessment for the use of bed rails as a restraint for one resident. Observations showed the resident had bed rails in the up position on both sides of the bed and was unable to lower the rail independently due to left-sided paralysis and limited hand mobility following a stroke. The resident reported using the bed rails frequently and stated they prevented him from getting out of bed. Staff interviews confirmed that the resident was assessed and the use of bed rails was discussed, but the documentation did not reflect that the bed rails functioned as a restraint, nor did it indicate that the resident could not remove them independently. Review of the resident's records showed physician orders for bed rails for mobility, but the Assistive Device/Restraint Initial Evaluation did not identify the bed rails as a restraint or document that they limited the resident's movement. The facility's policy defined a restraint as any device the resident cannot remove easily, which restricts freedom of movement, and specified that the definition is based on the resident's functional status. The assessment failed to address these criteria, resulting in incomplete documentation and assessment for the use of bed rails as a restraint.
Failure to Ensure Timely Medication Administration and Adequate Nursing Staff Competency
Penalty
Summary
The facility failed to ensure competent nursing staff were available to provide timely medication administration and to meet residents' physical and psychosocial needs. One resident reported issues with a travel nurse, including concerns about the nurse's attitude and timeliness in completing care. Multiple residents had also complained about the care provided by travel nurses, as documented in resident council meeting minutes. Staff responsible for covering nurse call-offs stated that some travel nurses did not request assistance when running late, resulting in late medication administration. The facility primarily relied on travel nurses due to recruitment challenges, with only one full-time nurse on staff. A review of medication administration records for a resident showed that several medications, including Lisinopril, Cystex, Miralax, and acetaminophen, were administered significantly later than the scheduled times on multiple occasions. Facility policy allows a one-hour window before and after the scheduled time for medication administration, but the medications in question were given well outside this window. The facility's staffing plan and competency requirements were reviewed, but the deficiency was related to the actual practice of timely medication administration and the ability of staff, particularly travel nurses, to meet residents' needs.
Failure to Consistently Manage Pain for Hospice Resident
Penalty
Summary
The facility failed to ensure effective and consistent pain management for a hospice resident, resulting in unnecessary pain and discomfort. Observations and interviews revealed that the resident, who was under hospice care for advanced and progressive disease, received regular doses of ibuprofen and acetaminophen as ordered, but there were concerns from family members and staff regarding delays in administering stronger pain relief, such as morphine. Nursing staff often waited for up to an hour after giving acetaminophen or ibuprofen before considering morphine, even when the resident continued to experience significant pain. Documentation showed that morphine was only administered after repeated requests or when pain persisted despite initial interventions. Review of medication administration records and nursing notes indicated inconsistent documentation of pain assessments and follow-up after pain medication was given. For several months, there was no evidence of regular pain level monitoring, despite a care plan that required pain to be assessed using a 0-10 scale twice daily. When pain was documented, such as shoulder pain rated at 5/10 or 7/10, morphine was not always promptly administered, and family members had to advocate for stronger pain relief. In some instances, morphine was only given after multiple doses of acetaminophen or after direct requests from the resident or family. The facility's hospice plan of care emphasized the goal of relieving or reducing pain and required staff to assess pain characteristics and evaluate responses to medication. However, the records showed that these interventions were not consistently followed, and the resident's pain was not always managed according to the established plan. The lack of timely administration of appropriate pain medication and incomplete documentation of pain assessments contributed to the deficiency in providing adequate comfort and symptom control for the hospice resident.
Inadequate Infection Control Training for Temporary Staff
Penalty
Summary
The facility failed to ensure that temporary agency staff were trained on its infection prevention and control program standards, policies, and procedures. This deficiency was identified through observations, interviews, and record reviews. A traveling CNA, employed for approximately six months, reported that infection control training was not part of her on-board training. During an observation, this staff member did not perform proper hand hygiene. Another traveling employee, hired in mid-August 2024, also stated she did not receive infection control training upon starting. A third traveling employee, employed for about three months, confirmed that infection prevention and control was not included in her orientation. When documentation of infection control training for these staff members was requested, it was confirmed that no such documentation existed.
Failure to Adhere to Standard Precautions in Resident Care
Penalty
Summary
Staff member C failed to adhere to standard precautions related to the use of personal protective equipment and hand hygiene while providing personal care to a resident. During an observation, staff member C donned gloves without sanitizing her hands beforehand and entered the resident's room. She assisted in repositioning the resident and removed a soiled incontinence brief, cleaned the resident's peri area, and disposed of the brief without changing her gloves. Subsequently, she continued to assist with placing a Hoyer lift sling under the resident, removed the resident's clothing, and put on clean clothing, all while still wearing the dirty gloves. Staff member C then placed a clean incontinence brief into the resident's clothing cabinet and used the Hoyer lift to move the resident to a wheelchair, still without changing her gloves. After gathering the garbage, she finally removed the dirty gloves and washed her hands with soap and water. During an interview, staff member C acknowledged that she should have changed her gloves after cleaning the resident and sanitized her hands before donning and after doffing gloves. The facility's policy on standard precautions, last revised in April 2020, requires hand hygiene before and after resident contact and changing gloves to prevent cross-contamination when moving from a dirty task to a clean one.
Inaccurate MDS Coding for Diagnoses and Restraints
Penalty
Summary
The facility failed to ensure accurate coding of MDS assessments for several residents. For one resident, a diagnosis of dementia was added by the physician but was not reflected in the resident's Quarterly MDS. The diagnosis was documented in the resident's EMR only after the survey began, indicating a lack of a fail-safe mechanism to ensure new diagnoses are promptly updated. Staff interviews confirmed the oversight and the absence of a reliable process to update diagnoses after provider visits. Additionally, the facility failed to accurately document the use of bed rails and alarms in the MDS assessments for three other residents. One resident was observed with a chair alarm that was not documented in the MDS, and another resident had a bed rail that was not recorded. Conversely, a third resident's MDS inaccurately indicated the use of a bed rail that was not present. Staff interviews revealed inconsistencies and errors in MDS coding, as well as a lack of updated physician orders regarding the use of alarms and bed rails.
Failure to Update Care Plans for Medical Status and Equipment Usage
Penalty
Summary
The facility failed to revise care plans to reflect the medical status and equipment usage for two residents. For one resident, the physician's order to check blood glucose levels was discontinued on 4/12/24, but the care plan was not updated to reflect this change, leading to a lack of blood sugar monitoring. Additionally, the resident's care plan was not updated to include the use of a wheelchair, which was provided by hospice, despite observations of the resident using the wheelchair in the Day Room and dining room. For another resident, the care plan was not updated to reflect the removal of bed rails, which the resident no longer wanted. The care plan still indicated the use of bed rails, and there was no order obtained to discontinue their use. Staff interviews revealed that the care plans were not updated in a timely manner, and the facility's policy on care plan updates was not followed.
Failure to Implement Bed Rail Intervention and Update Care Plan
Penalty
Summary
The facility failed to implement the intervention of bed rails and update the care plan for a resident. During observations on two separate days, it was noted that the resident did not have bed rails on the bed, despite a physician's order dated several months prior indicating the use of a right bed side rail for bed mobility and repositioning. The resident's care plan also indicated the use of a side rail per the resident's request. Interviews with staff revealed confusion about the presence of bed rails, with one staff member noting that the bed rails were not installed after the resident moved rooms, and another stating that the resident did not want the bed rails anymore, although there was no order to discontinue their use.
Latest citations in Montana
A dependent resident admitted post-surgery with intact but vulnerable skin and MASD risk developed significant bilateral buttock MASD and a sacral pressure injury that progressed from deep tissue injury to Stage III and then to a large unstageable ulcer with odor and purulent drainage. Facility records showed incomplete and missing weekly skin/wound assessments during the period when the wound worsened, despite a care plan calling for skin evaluations, turning/repositioning, CNA skin inspections, and monitoring of nutrition. Staff interviews revealed they were frustrated by the resident’s anxiety and behaviors, reported the sacral wound as facility-acquired, acknowledged the resident became obtunded on an intense opioid regimen, and stated they were unaware of excessive fluid intake and could not explain why the worsening wound and infection were not recognized or reported before the resident required hospital transfer for a severe sacral decubitus ulcer with associated infection.
Surveyors found that kitchen staff failed to properly label and date multiple food items stored in the walk-in cooler, including slimy sliced tomatoes, ground meat, sliced ham, roast beef, cheese, and strawberries. Staff reported that they sometimes picked moldy strawberries out of shipments and that moldy dinner rolls had been served and then collected from residents. These practices did not follow the facility’s written policy requiring labeling, dating, and monitoring of refrigerated foods so they are used by their use-by date or discarded, placing all residents at risk for foodborne illness.
The facility failed to submit required investigation findings to the State Survey Agency (SSA) within 5 working days for multiple abuse and elopement incidents. In one case, a resident kicked another resident’s feet, and in another, one resident kicked another in the legs while both were in wheelchairs; in both situations, the facility did not provide timely or, in one case, any investigative findings to the SSA. The facility also reported two separate elopement events for a resident but did not submit final investigation reports for either incident. A staff member reported that another staff member, who was absent during the survey, was responsible for SSA reporting, and confirmed the expectation to report all investigation results within 5 working days per facility policy.
Two residents were involved in a resident-to-resident abuse incident in which one resident kicked another multiple times while both were in wheelchairs, and although staff separated them and documented the event, the facility did not complete or document a formal abuse investigation, did not ensure ongoing protection from further confrontations, and did not report investigative findings to the SSA. In addition, several residents experienced multiple elopements, with documentation that one resident followed others out back doors and another exited through doors into a hospital area, yet the facility’s investigation files lacked clear timelines, comprehensive staff interviews, identification of information sources, and root-cause analyses of exit-seeking behavior. Staff interviews confirmed that while nurses submitted occurrence reports and SSA notifications and discussed root causes informally, management did not consistently document thorough investigations or root-cause findings as required by facility policy.
The facility failed to provide adequate supervision and effective elopement-prevention interventions for several cognitively impaired, exit-seeking residents who were known elopement risks. Despite assessments, care plans, anti-wandering devices, and door alarms, residents repeatedly exited through front and back doors without timely staff redirection or alarm response, and some elopements were not properly documented in the EHR. One resident with dementia and short-term memory loss was not care planned for elopement until after multiple attempts, and another resident with severe cognitive impairment left through sliding doors unnoticed. A resident with an anti-elopement alarm on her wheelchair repeatedly triggered the door alarm throughout the day, yet staff did not effectively respond, allowing her to exit unsupervised and fall on stairs, sustaining minor injuries.
The facility failed to provide meaningful, resident-centered activities for multiple dementia residents in the memory care unit, resulting in individuals sitting idle in dining and common areas, staring at blank or inappropriate televisions, sleeping in chairs, or wandering hallways without engagement. Activity sessions were canceled or not implemented as scheduled, and when paper activities like word searches were offered, only a few residents participated while others received no assistance, including a resident who repeatedly requested glasses and another who did not speak English. Sitters did not help residents with activities, and an activity staff member spent time on a computer and left the unit for other duties. Staff interviews revealed that management directed the limitation of music and physical activities, that residents were often left in bed because it was easier for staff, that floor staff did not conduct activities in the absence of the activity staff, and that the posted activity calendar, which included exercise, trivia, book club, and weekend "Resident Choice Day," was frequently not followed despite a policy requiring meaningful activities tailored to dementia residents.
A hospice resident with metastatic cancer and behavioral symptoms received multiple sedating medications, including quetiapine, hydrocodone, morphine, lorazepam, olanzapine, and prednisone, without thorough assessment for unnecessary drugs, duplicate therapy, or adverse consequences. Despite documented behavioral issues, falls, cognitive decline, and moderate to severe pain scores, staff reported no concerns with the medication regimen. The resident became increasingly sedated, was found unconscious with minimal response to painful stimuli, and was sent to the hospital, where documentation linked the clinical picture to disease progression and medication effects, including opioid use and possible steroid-induced psychosis.
A resident with a documented history of opioid-induced constipation and prior fecal impaction was admitted from the hospital, where providers had noted difficulty balancing opioid use and constipation medications. On admission, facility documentation characterized the resident as having normal stool and rarely needing laxatives. Over the following weeks, bowel records showed multiple days without a bowel movement, yet the MAR reflected no scheduled or PRN constipation medications given. Nursing notes documented no constipation despite absent bowel sounds, while subsequent hospital imaging revealed an extensive rectal stool burden concerning for stercoral colitis. Staff interviews confirmed that the prolonged absence of bowel movements was not reported, the resident received no PRN bowel medications, and there was no specific bowel and bladder management policy.
Staff failed to follow hand hygiene practices while caring for a resident with weeping, hot lower legs who had been started on antibiotics for cellulitis. One staff member removed TED hose from the resident’s weeping left leg and then immediately assessed the right leg without changing gloves or performing hand hygiene. Another staff member, after applying TED hose to the weeping leg while gloved, continued to handle the resident’s food, pillow, and personal items and answered a cell phone by placing her gloved hand into her pocket, all without changing gloves or performing hand hygiene, contrary to the facility’s hand hygiene policy.
The facility failed to protect residents from abuse when one resident without capacity to consent was found in a common area with another resident’s hand inside her brief, and the subsequent investigation did not include interviewing or assessing other residents who might have been affected. In a separate event, a resident shook his spouse’s head and later sprayed water in her face with a spray bottle when she was tired at dinner, causing her agitation, while both continued to share a room and she spent most of her time and slept in common areas due to ongoing behaviors between them, as reflected in her care plan.
Failure to Prevent and Manage Pressure Ulcer Leading to Severe Sacral Wound
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate prevention and treatment of pressure ulcers and to complete and document required skin and wound assessments for a dependent resident. The resident was admitted from a hospital with red skin on the right elbow, a left neck surgical laminectomy site, and a left shin abrasion, and was totally dependent on staff for bed mobility, transfers, dressing, toileting, personal hygiene, and bathing, and had a Foley catheter. Within six days of admission, weekly wound documentation showed the resident had developed bilateral buttock moisture-associated skin damage (MASD) of significant size. The resident was then hospitalized for confusion and hyponatremia, and hospital wound care documented a deep tissue pressure injury to the sacrum that evolved into a Stage III pressure injury with yeast. When the resident returned to the facility, the facility’s readmit screener documented MASD to the buttocks and a yeast rash to the buttocks and groin, but no sacral pressure injury. Subsequent facility wound documentation showed that a few days after readmission, the resident had scattered ulcerations with MASD to the buttocks and a Stage III pressure ulcer to the right medial lower buttock, and that orders for treatment were requested from the physician. By the following week, the weekly wound observation tool documented that the Stage III bilateral buttock wounds had merged into one large unstageable pressure ulcer with odor and moderate purulent drainage, indicating potential infection. During this same period, there were no documented skin/wound assessments for the week leading up to the resident’s transfer back to the hospital, and a staff member later stated she did not know where the assessments were or why they were not done, and could not explain why no one reported that the wound was worsening. The care plan listed multiple skin integrity problems and interventions, including skin evaluations, routine turning and repositioning, CNA skin inspections with routine care, monitoring nutrition, and weekly nurse skin evaluations, but did not specify task frequency for some interventions. Interviews further described staff awareness and handling of the resident’s condition and behaviors. A family member reported that staff were frequently frustrated by the resident’s constant need for attention and anxiety, and that he repeatedly educated management about the resident’s high anxiety and hyperfocus, and did not understand how staff could report spending so much time with the resident yet not recognize how sick he was with infection. A staff member stated the sacral wound was facility-acquired, that the resident became obtunded related to opioids, and that she was unaware of the resident’s excessive water intake until after a hospital stay. Another staff member who completed a readmission history and physical found the resident febrile, with therapy unable to mobilize him due to pain, and described the resident as heavily sedated on an intense pain regimen that predated his stay. This staff member stated there were many opportunities for improvement in nursing assessments and that the facility could not handle the resident’s complex psychiatric and pain needs. Ultimately, the resident was transferred to the hospital with a large sacral decubitus wound with purulent tissue, surrounding cellulitis, and radiologic evidence of a severe sacral ulcer with erosion nearly to the coccyx and associated abscess and necrotizing soft tissue infection.
Improper Labeling, Dating, and Handling of Refrigerated Food Items
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage practices when, during an observation of the walk-in cooler, multiple food items were found undated or unlabeled, contrary to the facility’s Food Safety Requirements policy. Specifically, two zip-lock bags of slimy, sliced tomatoes were not dated; a gallon zip-lock bag of ground meat was not labeled with the food type or date; and separate gallon zip-lock bags of sliced ham, sliced roast beef, and sliced cheese were all undated. In addition, a cup of sliced strawberries had no date. Staff interviews revealed that kitchen staff had observed mold on strawberries upon delivery and would usually attempt to pick out the molded strawberries, and another staff member acknowledged awareness of ongoing dating issues with refrigerated foods. A further interview indicated that moldy dinner rolls had been served on one occasion, prompting staff to retrieve the rolls from residents after service. The facility’s written policy required labeling, dating, and monitoring refrigerated food, including leftovers, so it would be used by its use-by date or frozen/discarded, but these requirements were not followed, placing all residents at risk for foodborne illnesses. No specific residents or their medical histories were identified in the report; the deficiency was described as affecting all residents through improper food labeling, dating, and handling practices in the kitchen and walk-in cooler.
Failure to Submit Abuse and Elopement Investigation Findings Within Required Timeframe
Penalty
Summary
The facility failed to submit investigation findings related to alleged abuse and elopement incidents to the State Survey Agency (SSA) within the required 5 working days for multiple residents. For one incident dated 1/24/26, a resident left her room and kicked another resident’s feet; the facility’s investigative findings for this event were not submitted to the SSA until 2/4/26, which was 11 days after the incident was reported. For another incident dated 3/20/26, one resident kicked another resident in the legs while both were in wheelchairs, with no injuries reported and immediate separation of the residents; review of records showed no evidence that the facility ever submitted investigative findings for this incident to the SSA. Additionally, review of the SSA reporting site showed that the facility made initial reports of elopement for a resident on 7/18/25 and 2/1/26 but did not submit final investigation reports within the required 5 working days. There were no final reports for either elopement incident. During an interview, a staff member stated that another staff member, who was out of the facility during the survey week, was responsible for reporting and submitting investigative findings to the SSA for abuse allegations. The same staff member confirmed the expectation that findings of any abuse allegation be reported to the SSA within 5 working days and acknowledged they could not provide investigative findings for the 3/20/26 incident. The facility’s written policy, reviewed and dated 7/15/25, required that results of all investigations of alleged violations be reported within 5 working days of the incident.
Failure to Investigate Resident Abuse and Elopements or Identify Root Causes
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and manage an allegation of resident-to-resident abuse and multiple resident elopements. In one incident, a resident in a wheelchair kicked another resident multiple times in the lower legs while both were at the nurses’ station. Nursing documentation noted the kicking and that there were no injuries, and the immediate response was to separate the residents. However, review of the facility’s abuse investigations for the relevant period showed no completed investigation related to this reported allegation of resident-to-resident abuse, and there was no documentation of investigative findings or that these findings were reported to the State Survey Agency. The facility also failed to protect the involved residents from further potential abuse. Nursing notes for both residents documented that, two days after the kicking incident, one resident was observed continually attempting to follow, communicate with, agitate, and argue with the other resident, and staff had to separate them twice. Staff communicated to others to monitor their interactions, but the notes showed that the residents continued to have problematic contact, indicating that the facility did not prevent further potential abuse between them. During interview, a staff member stated that another staff person was responsible for investigating and reporting abuse allegations, but that person was unavailable and no documentation could be produced to verify that an investigation had been completed or that results were reported to the state agency, despite facility policy requiring thorough investigation, protection of residents during the investigation, and reporting of results. The deficiency also includes failures related to multiple elopements by several residents. For one resident, an elopement investigation documented that the resident exited the facility, but the investigation lacked signatures, identification of information sources, and clear involvement of the email sender included in the file. A state abuse reporting entry indicated that this resident left through back doors, possibly following a volunteer or staff taking other residents to Mass, and was brought back by a Med-Surg nurse, but there was no documented root-cause analysis or explanation of why the elopement occurred or what interventions were implemented to prevent recurrence. Another resident eloped through doors leading into the hospital; the reportable incident was submitted to the SSA, but there were no nurses’ notes on the date of the elopement describing the event, and a note the following day only stated that the resident attempted to elope twice, reflecting incomplete contemporaneous documentation. For this same resident, the facility’s investigation of the elopement included only limited staff interviews and did not include interviews with CNAs or activity staff to establish a full timeline of the resident’s movements or to identify the root cause. A subsequent elopement by this resident into the hospital was documented in a nursing note, and the investigation consisted of an undated handwritten note stating that people came into the unit looking for someone in the hospital, left to go to Med-Surg, and the resident followed them out the door, with the door alarm functioning and the resident returning to the unit. There was no documented timeline, no detailed interviews, and no analysis of the effectiveness of elopement-prevention interventions. A third resident had multiple documented elopements over several months, with investigation files that often contained only brief summaries, incomplete checklists, or limited supporting documents such as bounds reports or invoices for a wander guard system. Across these events, the facility did not consistently document root-cause analyses or assessments of the resident’s exit-seeking behavior, and the record notes that this failure to identify and document root causes led to a fall with injury for this resident. Interviews with staff confirmed that the facility’s practice did not align with its stated expectations. One staff member reported that a former staff person had previously conducted incident investigations but had left months earlier, and that the expectation for investigations was to determine the root cause of incidents and monitor residents to ensure interventions were implemented. Another staff member stated that after each elopement, the nurse would file a report to the SSA and update the care plan, after which management was supposed to conduct a full investigation. A further interview indicated that nurses entered occurrence reports and submitted SSA reports to track elopements and that staff discussed root causes but did not maintain documentation of those analyses. These statements, combined with the incomplete and inconsistent investigation records, demonstrate that the facility did not carry out or document thorough investigations, root-cause analyses, or protective measures as required by its own abuse investigation and reporting policy.
Failure to Prevent Elopements and Respond to Anti-Wandering Alarms
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and effective interventions to prevent elopements for multiple residents identified as at risk for wandering, despite existing assessments and care plans. Staff reported that residents at risk for elopement were identified by the MDS nurse on admission and quarterly, and that anti-wandering devices and door alarms were in place, particularly at the front door. However, staff also indicated that wander guard bracelets could be applied without formal assessment, and that information about elopement risk was communicated via paper “brain” sheets. The facility had a written SBAR and procedure for anti-wandering door alarms, including immediate resident location checks and following an elopement procedure, but the report shows these processes were not effectively implemented. One resident with a documented elopement risk and dementia was care planned to have an anti-wander device on her wheelchair and to be involved in activities and redirected when she attempted to exit. She eloped on at least two occasions: once when she went through the first set of doors and was found in a corridor by another resident, and another time when she exited through back doors, apparently following others going to Mass, with no alarms triggered. Her care plan documentation was inaccurate regarding the presence of a wander guard door in 2024, and there was no nursing documentation of the February elopement in her electronic health record. Another resident with severe cognitive impairment (BIMS score of 3) and an elopement risk care plan that included redirection, diversional activities, and ensuring door alarms were activated, was able to get out between the sliding front doors when someone was entering or exiting, and no one saw her leave, contrary to the care plan interventions. A further resident with dementia and short-term memory problems was identified as at risk for elopement, yet his elopement care plan and interventions were not initiated until after he had already eloped twice in one afternoon through different doors. He later eloped again, but the corresponding nursing note was not provided. Another resident, described as exit seeking and very independent with behavioral issues toward staff, had an anti-elopement alarm device on her wheelchair that sounded as she approached the door and had been near the door setting off the alarm throughout the day. Despite this, she was able to push open the main entrance sliding doors, exit, and then fall while attempting to walk down stairs, sustaining an abrasion and bruising and requiring hospital evaluation. Staff interviews indicated that interventions such as 1:1 monitoring, taking her outside, and diversional tasks were used, and that elopements were tracked via occurrence reports and state submissions, but the facility failed to identify the need for continuous one-on-one monitoring for this resident, failed to respond appropriately to the anti-elopement door alarm, and failed to prevent her unsupervised exit and subsequent fall. Activity staff also reported that, after a staffing reduction, there were no organized activities after 5 p.m., despite prior recognition that increased monitoring and activities during late afternoon hours were needed for an elopement-risk resident.
Failure to Provide Meaningful Activities for Dementia Residents in Memory Care Unit
Penalty
Summary
The deficiency involves the facility’s failure to provide meaningful, resident-centered activities to meet the needs of multiple residents with dementia in the memory care unit. Surveyors observed residents sitting in dining and common areas without any activities, including a resident with a BIMS score of 0 repeatedly scratching her arms while staring at a turned-off television, and another resident wandering the unit and running into walls. On another observation, the scheduled activities were canceled due to weather, and the activity staff member present was working on care plans on a computer while residents sat with newsletters in front of them, many staring at the floor or sleeping. Only some residents participated in the offered activities, while others, including residents with severely and moderately impaired memory, did not participate and were not engaged. During the same observation period, residents were given a word search activity, but only a few actively worked on it. Sitters, who were present to watch and redirect residents, sat at the tables and did not attempt to assist residents with the activity. One resident repeatedly stated she needed her glasses to see the paper, but no staff obtained her glasses. A resident who did not speak English sat staring down the hall without engagement, and another resident with severe cognitive impairment wandered the hall. The activity staff member stated she had other duties in another unit and left, and later that evening, surveyors observed one resident sleeping in a recliner and another staring at a wall while cartoons played on the television. Interviews with staff revealed that activities in the memory care unit were limited and often not implemented as scheduled. The activity staff member reported she was instructed by management to avoid music and physical activities because staff believed these would cause residents to become agitated, and that she was told to limit activities to calming options only. She also stated that residents were often left in bed and not taken to activities because it was easier for staff, and that floor staff did not provide activities when she was not present, preferring residents to sit quietly. Other staff confirmed that activities usually did not occur in the memory care unit, that activities observed during the survey were a show for surveyors, and that the activity calendar was not followed. The memory care activity calendar showed “Resident Choice Day” on all weekends and listed trivia, exercise/stretching, and book club on weekdays, while the facility’s activities policy required activities to enhance well-being, physical activity, cognition, and to provide meaningful activities for residents with dementia.
Failure to Assess Hospice Resident’s Polypharmacy and Sedation Risk
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s drug regimen was free from unnecessary medications and thoroughly assessed for sedation, duplicate therapy, and adverse consequences. A hospice resident with metastatic cancer, delirium, psychosis, and impulsive, intermittently aggressive behavior was receiving multiple medications including antipsychotics, opioids, benzodiazepines, and a steroid. Hospice staff discontinued some medications and added morphine and lorazepam, while the resident also continued on quetiapine, hydrocodone, prednisone, and later received a one-time dose of olanzapine. Facility staff A and B reported that they had no concerns with the resident’s medications despite the combination of psychotropic and sedating drugs. The resident had been ambulatory on arrival to the facility but became weaker with multiple falls, nonsensical and incoherent speech, and combative and unsafe behavior. One-to-one supervision was initiated due to impulsivity and aggression, and staff questioned whether pain contributed to the aggressive behavior. The resident’s pain scores documented on the Medication Administration Record over three days showed moderate to severe pain levels (5/10, 3/10, and 7/10), while the resident continued to receive multiple sedating medications, including quetiapine every eight hours, hydrocodone three times daily, lorazepam as needed every four hours, morphine as needed every four hours, and prednisone daily. On the day before transfer to the hospital, the resident received olanzapine, prednisone, hydrocodone, two doses of lorazepam, and morphine; on the day of transfer, the resident received lorazepam, morphine, and prednisone. When a family member arrived at the facility, they found the resident unconscious with minimal response to painful stimuli and appearing sedated, and they requested transfer to the hospital. The family reported the resident had been more sedated at the facility lately, and the emergency room provider reportedly told the family the resident had an overdose of medications. Hospital documentation noted altered mental status, hypoxia, and that the resident’s dementia and chronic encephalopathy may have been exacerbated by disease progression and opioid use, possible steroid-induced psychosis, and electrolyte imbalance. The facility did not identify or address the resident’s medication regimen as a contributing factor to sedation or assess for duplicate therapy and adverse consequences prior to the resident’s transfer.
Failure to Monitor and Treat Constipation in Resident With Opioid-Induced Constipation History
Penalty
Summary
The facility failed to monitor and manage constipation for a resident with a known history of opioid-induced constipation and prior use of constipation medications. Hospital records showed the resident had been admitted with a 9.6 cm fecal impaction and that the hospital physician documented the resident could go up to five days without a bowel movement, likely due to opioid use, and was working on balancing opioid-induced constipation with constipation medications. Upon admission to the facility, the Admit/Readmit Screener documented that the resident had normal formed stool and rarely or never depended on laxatives, despite this history. Facility bowel documentation later showed gaps in bowel movements, including no bowel movement for several days. Review of the Medication Administration Record for March and April showed the resident did not receive any scheduled or PRN constipation medications during the stay. Bowel documentation indicated no bowel movement from 3/29 to 4/3, followed by diarrhea on 4/4 and a putty-like stool on 4/5. A nursing progress note on 4/6 documented a flat, non-tender abdomen with no bowel sounds and no constipation, while hospital records from the same date, after readmission, showed an extensive stool burden distending the rectum to 8.8 cm with findings concerning for stercoral colitis. Staff interviews revealed that no one reported the resident had gone six days without a bowel movement, the resident had gone without any PRN bowel medications, and the facility did not have a policy specific to bowel and bladder management.
Failure to Perform Hand Hygiene During Wound and Skin Care
Penalty
Summary
Facility staff failed to ensure proper hand hygiene during care of a resident with suspected infected lower extremities. During an observation, two staff members entered the room of a resident who had reported weeping and hot lower legs. One staff member removed the TED hose from the resident’s left leg, noted that the leg was hot to the touch and weeping edema fluid, then moved directly to the right leg, removed the TED hose, and assessed that leg without changing gloves or performing hand hygiene between contact with the weeping left leg and the intact right leg. This same staff member later stated she believed she had completed all hand hygiene opportunities but realized, when questioned, that she had moved from one leg to the other without performing hand hygiene. The resident had been started on Cipro for cellulitis on the morning of the observation. A second staff member returned to the room with new TED hose and socks, donned gloves, and assisted with applying the TED hose. This staff member applied TED hose to the resident’s left leg, observed weeping fluid from the skin, and then proceeded to clean up the room while still wearing the same contaminated gloves. While gloved, she touched the resident’s food on the bedside table, handled the resident’s pillow and placed it on the chair where the resident was sitting, and put her gloved hand into her clothing pocket to turn off her ringing cell phone. She did not perform hand hygiene or change gloves after contact with bodily fluids and before touching other items in the room. After leaving the room, she stated she had not thought about performing hand hygiene after finishing application of the TED hose. The facility’s hand hygiene policy required hand hygiene after handling contaminated objects, when moving from a contaminated site to a clean body site during resident care, and after handling items potentially contaminated with blood or bodily fluids.
Failure to Protect Residents From Sexual and Physical Abuse by Other Residents
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from abuse, including sexual and physical abuse, by other residents. In one incident, a resident without capacity to consent was found in a common area with another resident’s hand inside her brief up to the wrist. Staff immediately separated the residents, and the incident was reported to the State Survey Agency; however, the facility’s investigation did not include interviewing or assessing other residents who might have been present or potentially affected by similar sexual abuse incidents. A staff member also reported that the incident was initially reported under the wrong license type because they were unaware the facility held both an adult day care and a skilled nursing facility license. In a separate incident, a resident became upset with his spouse, also a resident, during dinner and shook her head to wake her, then later sprayed water in her face with a spray bottle after staff had intervened and moved her to the nurses’ station. The spouse became agitated by these actions. Observations showed that the couple continued to share a room, with both residents’ nameplates and belongings present. Staff interviews indicated that the spouse who was the target of the behavior was usually kept out of the room and spent most of her time and slept in common areas or by the nurses’ station due to ongoing behaviors between the two. The care plan for the spouse reflected that she was not to be in the room when her husband was present unless both wanted to be there, and staff were to intervene if yelling occurred, based on the prior incident of head shaking and use of the spray bottle.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
