Sweet Memorial Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Chinook, Montana.
- Location
- 125 Airport Rd, Chinook, Montana 59523
- CMS Provider Number
- 275127
- Inspections on file
- 22
- Latest survey
- January 29, 2026
- Citations (last 12 mo.)
- 23
Citation history
Health deficiencies cited at Sweet Memorial Nursing Home during CMS and state inspections, most recent first.
A deficiency was cited for failing to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, due to inadequate safeguards and oversight.
The facility did not report initial allegations or final summaries of abuse, neglect, or misappropriation of property to the State Survey Agency within required timeframes. Incidents included delayed reporting of suspected drug diversion, physical altercations between residents, and unexplained bruising, with staff confirming that notifications to authorities and final summaries were not made promptly.
The facility did not thoroughly investigate multiple alleged abuse incidents and unexplained bruising among residents. In several cases, altercations such as slapping, choking, and physical aggression were not followed by interviews, root cause analysis, or preventive interventions. Documentation was incomplete, and staff relied only on event reports without conducting further investigation.
The facility did not complete the care plan within 7 days of the comprehensive assessment, and the care plan was not prepared, reviewed, and revised by a team of health professionals as required.
The facility did not maintain a secure or detailed system for tracking controlled substances, allowing significant quantities of medications to go missing for several residents. A nurse continued to access and sign for narcotics for months after discrepancies were first identified, and the consultant pharmacist was not promptly involved in the investigation or monitoring. The facility's policy for immediate notification and reconciliation was not followed, leading to delayed reporting to authorities.
Two residents did not receive appropriate social services interventions after experiencing abuse from another resident, including one who felt isolated and vulnerable after being moved and another who was left upset and crying. Staff failed to assess or document the residents' psychosocial well-being following these incidents, and required depression assessments were not completed as scheduled.
The facility failed to investigate resident-to-resident altercations involving three residents. A staff member suspected an injury was due to an unwitnessed altercation, but the report did not explore this. In another case, two incidents of physical altercations were reported, lacking observations, interviews, and corrective actions. A staff member downplayed the incidents as mistreatment due to cognitive impairments.
The facility failed to oversee personal refrigerators in resident rooms, affecting three residents. Observations revealed missing temperature gauges and unlabeled food items, with one refrigerator having a thick ice buildup. Staff interviews showed unclear responsibility for refrigerator management, and the facility could not provide a relevant policy.
The facility failed to update care plans for several residents, including the discontinuation of a catheter, oxygen use, and bed rails. Additionally, a resident and their representative were not involved in the care planning process. Staff acknowledged the need for improvements in care planning.
The facility had a medication error rate of 8.16%, exceeding the acceptable limit of 5%. Errors included incorrect dosages of gabapentin and vitamin B-12 for two residents, and a failure to document held medications for another resident due to low blood pressure. These issues were identified during observations and interviews with staff.
A staff member failed to perform hand hygiene between administering medications to multiple residents. Despite touching residents' eating utensils and dishes, the staff member did not wash hands between residents, believing it unnecessary as she did not touch the pills directly. Upon interview, the staff member acknowledged the oversight.
A resident with severe cognitive impairment was struck twice by another resident who was having difficulty adjusting to the facility. The incidents were not classified as abuse by staff due to cognitive impairments and lack of injuries, but the facility failed to identify triggers or protect the resident from further abuse.
A facility failed to provide a baseline care plan to a resident or their representative. The resident reported not receiving any information about the care plan, and the representative confirmed the lack of communication. A review of the medical record showed no evidence of the care plan being provided, and no documentation was submitted upon request during the survey.
A facility failed to create a comprehensive care plan for a resident with broken and decayed teeth. Despite the resident's assessment indicating dental problems, the care plan lacked documentation or planning for dental services. A staff member confirmed that dental issues should be included in care planning, highlighting a lapse in the facility's process.
A resident experienced discomfort due to a poorly fitting wheelchair and the positioning of an oxygen tank. Despite informing CNAs, there was a lack of communication among staff, and the resident was not evaluated for proper wheelchair positioning during her physical therapy initial examination.
A resident experienced pain due to a callus on her left foot, which the facility failed to address appropriately. Despite a physician's order for a podiatry consult dated in September, the appointment was not scheduled. The resident reported ongoing pain, and an observation confirmed the presence of the callus. A staff member acknowledged that the consult had not been scheduled.
A facility failed to comply with the 14-day limit on as-needed antipsychotic medications for a resident with dementia, anxiety, and depression. The resident received olanzapine without the required physician evaluation and reordering every 14 days. Staff interviews revealed a misunderstanding of the policy and reliance on the EHR system to manage medication discontinuation, leading to a deficiency in medication administration practices.
The facility failed to discard expired Half and Half cartons in the walk-in cooler. Observations on consecutive days revealed cartons past their use by date, and a staff member confirmed that these should have been discarded, indicating a lapse in food safety protocols.
The facility failed to document and offer pneumococcal vaccines to two residents. One resident's history showed no record of receiving any pneumococcal vaccines, and the staff member responsible for immunizations could not provide information on the offering or declination of these vaccines. Another resident's history showed receipt of the Prevnar 13 vaccine but lacked documentation for Prevnar 20 or Pneumovax 23. The staff member was unable to explain the absence of these records.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report documents that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's protective measures and oversight. Specific details about the actions or inactions leading to the deficiency, as well as information about the residents involved or their conditions at the time, are not provided in the report. The deficiency centers on the lack of comprehensive protection for residents against abuse and neglect, as required by regulatory standards.
Failure to Timely Report Abuse, Neglect, and Misappropriation Incidents
Penalty
Summary
The facility failed to report initial allegations and final summaries of abuse, neglect, or misappropriation of property to the State Survey Agency within the timelines required by federal regulations for multiple residents. In one instance, a potential drug diversion involving resident medications was identified, but the facility delayed reporting the suspicion to the State Survey Agency and local law enforcement, choosing instead to complete an internal medication audit first. The initial report to the State Survey Agency was not made until several weeks after the investigation began, and law enforcement and the board of nursing were not contacted until even later. Additional incidents involved delayed reporting of physical altercations between residents and a case of unexplained bruising. In several cases, the initial reports or final summaries were submitted days after the events occurred, exceeding the required reporting timelines. Interviews with staff confirmed the delays and revealed a lack of immediate action in notifying authorities as required. The facility did not provide timely final summaries for several incidents, and in one case, no further investigation was conducted into the cause of a resident's bruising.
Failure to Investigate Alleged Abuse and Unexplained Injuries
Penalty
Summary
The facility failed to thoroughly investigate multiple alleged abuse incidents and unexplained injuries among residents. In one case, a resident was found with bruises of unknown origin on her foot, thigh, and calf, but there was no clear documentation in the medical record describing the bruises or their causes. Staff acknowledged that no further investigation was conducted beyond noting that the resident bruised easily, and no interventions or root cause analysis were completed. Additionally, several resident-to-resident altercations were not adequately investigated. These included incidents where one resident slapped, punched, or choked other residents, and another incident where a resident sprayed alcohol and sanitizer on another's face. The facility's documentation did not include interviews with involved parties, root cause analysis, or implementation of interventions to prevent recurrence. Progress notes often lacked details about the events, contributing factors, or steps taken to protect residents. Staff interviews revealed that the facility relied solely on event reports and risk management forms for investigations, with no further investigative actions taken.
Failure to Timely Develop and Review Care Plan
Penalty
Summary
The facility failed to develop the complete care plan within 7 days of the comprehensive assessment. The care plan was not prepared, reviewed, and revised by a team of health professionals as required. This deficiency was identified based on the review of facility records and documentation, which showed that the care planning process did not meet the specified timeline and team involvement requirements.
Failure to Secure and Monitor Controlled Substances Resulting in Drug Diversion
Penalty
Summary
The facility failed to maintain an adequate system for storing and monitoring controlled substances, resulting in missing medications for multiple residents. The investigation revealed that the facility used loose-leaf, unnumbered paper in a binder to track controlled drugs, which did not correspond to the medication cards and allowed for easy removal of both medication and records. This lack of a secure and detailed tracking system enabled discrepancies to go undetected, and several residents were found to be missing significant quantities of their prescribed medications, including Seroquel, Alprazolam, Mirtazapine, Tramadol, and Norco. The initial missing medication was identified when a resident ran out of Seroquel 14 days earlier than expected, and further review uncovered additional losses affecting other residents. Staff interviews indicated that a specific nurse was the common factor in the missing medication cases, yet this nurse continued to work and sign for narcotics for over two months after the first discrepancy was identified. The consultant pharmacist was not promptly informed of the diversion and did not participate in the investigation or monitor narcotics reconciliation logs. The facility's policy required immediate notification and monitoring in the event of discrepancies, but these procedures were not followed, and the local police and board of nursing were not contacted until months after the initial discovery of missing medications.
Failure to Provide Social Services After Abuse Incidents
Penalty
Summary
The facility failed to provide adequate medically-related social services to support the psychosocial well-being of two residents following incidents of abuse by another resident. One resident reported feeling isolated after being moved to a different area of the building due to repeated incidents involving another resident, including having hand sanitizer squirted in her eyes, which resulted in ongoing eye issues and feelings of vulnerability. Despite these events, there were no documented interventions or follow-up by social services to address her emotional well-being, and required assessments such as the PHQ-9 were not completed as scheduled. Another resident was observed crying and upset after being physically grabbed by the same resident, but staff attributed her distress to her usual behavior and did not assess or document her psychosocial or emotional health following the incident. Progress notes lacked information on interventions to prevent further abuse or to address the resident's emotional response to the event. These actions and omissions demonstrate a failure to ensure residents' highest practicable level of physical and psychosocial well-being through appropriate social services interventions.
Failure to Investigate Resident Altercations
Penalty
Summary
The facility failed to thoroughly investigate resident-to-resident altercations, alleged to be abuse, involving three residents. In one incident, a staff member reported an injury of unknown origin on a resident's forehead, suspecting it was not from a fall due to the resident's inability to get back into her wheelchair without assistance. The staff member believed the injury might have resulted from an unwitnessed altercation with her roommate, who was known to be aggressive. However, the facility's report did not explore this possibility or document the resident's room change for safety. In another case, two incidents of physical altercations between two residents were reported, where one resident was seen punching and hitting the other. The investigations lacked observations of the aggressor's interactions with others, interviews with residents and staff, and documentation of corrective actions to protect the victim and other vulnerable residents. A staff member involved in the investigation downplayed the incidents as mistreatment rather than abuse due to the cognitive impairments of the residents involved.
Lack of Oversight for Personal Refrigerators in Resident Rooms
Penalty
Summary
The facility failed to provide proper oversight for the use of personal refrigerators in residents' rooms, affecting three sampled residents. During observations, it was noted that the personal refrigerators lacked temperature gauges, which are necessary to ensure food is stored at safe temperatures. Additionally, there were multiple instances of food items being stored without labels or dates, and one refrigerator had a thick layer of ice built up inside and outside the freezer compartment. These deficiencies were observed in the personal refrigerators of three residents, indicating a lack of consistent management and oversight. Interviews with facility staff revealed a lack of clarity and responsibility regarding the management of personal refrigerators. A staff member from the housekeeping department indicated that the housekeeping supervisor was responsible for managing the refrigerators, but there was no clear protocol for when the supervisor was absent. Another staff member was unaware of how many residents had personal refrigerators or how they were managed for food safety. The facility was unable to provide a policy on personal refrigerators when requested, further highlighting the oversight issues.
Deficiencies in Care Plan Updates and Resident Involvement
Penalty
Summary
The facility failed to update and revise comprehensive care plans for several residents, leading to deficiencies in care documentation and planning. Resident #18's care plan did not reflect the discontinuation of a Foley catheter, despite a physician's order to begin bladder training and remove the catheter. Additionally, the care plan for resident #15 lacked details on the administration of oxygen, which was observed to be improperly used, and the resident experienced difficulty breathing without it. Furthermore, the care plans for residents #12, #18, and #27 did not document the use of bed rails or their intended purpose, indicating a lack of comprehensive care planning. The facility also failed to involve resident #20 or their representative in the care planning process. Resident #20 reported not being asked about their care plan, and their representative confirmed no communication from the facility regarding the plan of care. The electronic health record for resident #20 lacked documentation of their involvement in care planning, and no care plan meeting was held after the development of the comprehensive care plan. Staff member B acknowledged the need for updates and improvements in care plans, highlighting a gap in the facility's care planning process.
Medication Administration Errors and Documentation Issues
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a calculated error rate of 8.16%. This deficiency was observed in three residents. For one resident, a staff member incorrectly administered gabapentin by using a 1 ml syringe and filling it to the 0.1 ml line instead of the required 1 ml, leading to an underdose. The error was realized and corrected after the initial administration. Another resident was supposed to receive 5000 mcg of vitamin B-12 but was given only 500 mcg due to the staff member administering a single tablet of 500 mcg instead of the required dosage. Additionally, a staff member held two medications for a resident due to a systolic blood pressure reading below 110 mmHg, as per the facility's standing order. However, the staff member failed to document that the medications were held, and the Medication Administration Audit Report inaccurately showed that the medications were administered. This discrepancy was acknowledged by the staff member during a follow-up interview.
Failure in Hand Hygiene During Medication Administration
Penalty
Summary
The facility staff failed to perform proper hand hygiene during medication administration for three residents. During observations in the main dining room, a staff member was seen administering medications to residents without performing hand hygiene between each resident. Specifically, the staff member did not wash hands after administering medications to one resident before preparing medications for another. This occurred despite the staff member touching residents' eating utensils and dishes during the medication pass. When interviewed, the staff member acknowledged that she should have performed hand hygiene between residents but believed it was unnecessary since she did not touch the pills directly.
Failure to Protect Resident from Abuse by Another Resident
Penalty
Summary
The facility failed to protect a vulnerable resident from physical abuse by another resident. Resident #30, who had severe cognitive impairment and exhibited wandering behaviors, was struck on two separate occasions by resident #29. The first incident occurred on 10/17/24, when resident #29, who was having difficulty adjusting to the new environment, struck resident #30 on the right shoulder. The facility's investigation did not identify any possible triggers for the abuse or how resident #30 would be protected from further incidents. Additionally, resident #30's care plan did not address the increased risk of abuse due to her wandering behaviors. A second incident occurred on 10/24/24, when resident #29 hit resident #30 on the head and pulled her hair. Despite the facility's policy to prevent abuse, the care plan for resident #29 did not identify resident #30 as a potential target of abusive interactions. Staff members involved in the investigations of both incidents did not classify them as abuse, citing the residents' cognitive impairments and lack of injuries. However, the facility's failure to protect resident #30 from further abuse was evident, as no effective measures were implemented to prevent recurrence.
Failure to Provide Baseline Care Plan to Resident
Penalty
Summary
The facility failed to provide a copy of the baseline care plan to a resident or the resident's representative, as required. During an interview, the resident stated she did not receive any information or communication regarding her baseline care plan from the facility. Additionally, the resident's representative confirmed that they had not received any communication from the facility about the baseline care plan. A review of the resident's medical record showed no documentation or evidence that the baseline care plan was provided to either the resident or the representative. Despite a request for documentation regarding the provision of the baseline care plan, no information was provided before the end of the survey.
Failure to Address Dental Issues in Care Plan
Penalty
Summary
The facility failed to develop a comprehensive, resident-centered care plan for a resident with dental issues. During an observation, the resident was noted to have broken teeth in her lower jaw. The Social Service History & Initial Assessment documented that the resident had dental problems, specifically broken and decayed teeth. Despite this assessment, the resident's care plan did not include any documentation or planning related to her dental issues or the provision of dental services. A staff member confirmed that such issues should be care planned, indicating a lapse in the facility's care planning process.
Failure to Assess Wheelchair Positioning Needs
Penalty
Summary
The facility failed to identify and assess the wheelchair positioning needs for a resident, leading to discomfort due to a poorly fitting wheelchair. The resident reported that her wheelchair was too narrow and that the oxygen tank positioned on the back of her wheelchair caused her discomfort. Despite informing CNAs about the pain, there was a lack of communication and awareness among staff members regarding the issue. One staff member acknowledged being informed by the resident about the pain and had notified the maintenance department, but another staff member was unaware of any wheelchair maintenance concerns. Additionally, a review of the resident's physical therapy initial examination revealed that she was not evaluated for proper wheelchair positioning.
Failure to Provide Proper Foot Care for Resident
Penalty
Summary
The facility failed to provide appropriate foot care for a resident, resulting in the resident experiencing pain due to a callus on her left foot. The resident reported on December 2nd that she had been experiencing pain from the callus and that the facility had not addressed it. A progress note from September 6th indicated the presence of the callus and mentioned that the foot clinic had been treating it, with the resident expressing a desire for a podiatrist to evaluate the residual callus. A physician's order dated September 9th called for a podiatry consult for the callus, but the appointment was not scheduled. On December 4th, an observation confirmed the presence of the callus, and a staff member stated that the consult had not been scheduled despite the doctor's order.
Failure to Reorder PRN Antipsychotic Medication Every 14 Days
Penalty
Summary
The facility failed to ensure compliance with the 14-day limit on as-needed antipsychotic medications for a resident diagnosed with dementia, anxiety, and depression. The resident was prescribed olanzapine 2.5 mg twice daily as needed for agitation, but the order did not specify a duration or stop date. The resident's medication administration records (MAR) showed multiple doses were administered over several months without the required physician evaluation and reordering every 14 days. Despite a pharmacy progress note indicating the need for reordering, the medication was not appropriately managed, leading to a deficiency in medication administration practices. Interviews with facility staff revealed a lack of adherence to the policy requiring physician evaluation and documentation for the continuation of as-needed psychotropic medications. Staff members were aware of the 14-day limit but failed to ensure the medication was reordered as required. One staff member mistakenly believed the electronic health record system would automatically discontinue the medication, while another did not address the need for reordering in the monthly medication regimen review. The facility's policy on psychotropic medication use was not followed, resulting in the deficiency.
Failure to Discard Expired Dairy Products
Penalty
Summary
The facility failed to properly manage the storage of dairy products, specifically Half and Half, in their walk-in cooler. During observations on two consecutive days, cartons of Half and Half with a use by date of 12/3/24 were found on the top shelf to the right of the entrance. On 12/4/24, 11 cartons were observed, and on 12/5/24, eight cartons remained. During an interview, a staff member acknowledged that dairy products should have been discarded by their use by date, indicating a lapse in adherence to food safety protocols.
Failure to Document and Offer Pneumococcal Vaccines
Penalty
Summary
The facility failed to ensure proper screening and documentation for pneumococcal vaccinations for two residents. Resident #27's vaccination history did not indicate receipt of any pneumococcal vaccines, and staff member J, responsible for immunizations for two months, could not provide information on whether the vaccines were offered, received, or declined since the resident's admission. Similarly, resident #16's vaccination history showed receipt of the Prevnar 13 vaccine but lacked documentation of the Prevnar 20 or Pneumovax 23 being offered, given, or declined. Staff member J was unable to explain the absence of these records.
Latest citations in Montana
A dependent resident admitted post-surgery with intact but vulnerable skin and MASD risk developed significant bilateral buttock MASD and a sacral pressure injury that progressed from deep tissue injury to Stage III and then to a large unstageable ulcer with odor and purulent drainage. Facility records showed incomplete and missing weekly skin/wound assessments during the period when the wound worsened, despite a care plan calling for skin evaluations, turning/repositioning, CNA skin inspections, and monitoring of nutrition. Staff interviews revealed they were frustrated by the resident’s anxiety and behaviors, reported the sacral wound as facility-acquired, acknowledged the resident became obtunded on an intense opioid regimen, and stated they were unaware of excessive fluid intake and could not explain why the worsening wound and infection were not recognized or reported before the resident required hospital transfer for a severe sacral decubitus ulcer with associated infection.
Surveyors found that kitchen staff failed to properly label and date multiple food items stored in the walk-in cooler, including slimy sliced tomatoes, ground meat, sliced ham, roast beef, cheese, and strawberries. Staff reported that they sometimes picked moldy strawberries out of shipments and that moldy dinner rolls had been served and then collected from residents. These practices did not follow the facility’s written policy requiring labeling, dating, and monitoring of refrigerated foods so they are used by their use-by date or discarded, placing all residents at risk for foodborne illness.
The facility failed to submit required investigation findings to the State Survey Agency (SSA) within 5 working days for multiple abuse and elopement incidents. In one case, a resident kicked another resident’s feet, and in another, one resident kicked another in the legs while both were in wheelchairs; in both situations, the facility did not provide timely or, in one case, any investigative findings to the SSA. The facility also reported two separate elopement events for a resident but did not submit final investigation reports for either incident. A staff member reported that another staff member, who was absent during the survey, was responsible for SSA reporting, and confirmed the expectation to report all investigation results within 5 working days per facility policy.
Two residents were involved in a resident-to-resident abuse incident in which one resident kicked another multiple times while both were in wheelchairs, and although staff separated them and documented the event, the facility did not complete or document a formal abuse investigation, did not ensure ongoing protection from further confrontations, and did not report investigative findings to the SSA. In addition, several residents experienced multiple elopements, with documentation that one resident followed others out back doors and another exited through doors into a hospital area, yet the facility’s investigation files lacked clear timelines, comprehensive staff interviews, identification of information sources, and root-cause analyses of exit-seeking behavior. Staff interviews confirmed that while nurses submitted occurrence reports and SSA notifications and discussed root causes informally, management did not consistently document thorough investigations or root-cause findings as required by facility policy.
The facility failed to provide adequate supervision and effective elopement-prevention interventions for several cognitively impaired, exit-seeking residents who were known elopement risks. Despite assessments, care plans, anti-wandering devices, and door alarms, residents repeatedly exited through front and back doors without timely staff redirection or alarm response, and some elopements were not properly documented in the EHR. One resident with dementia and short-term memory loss was not care planned for elopement until after multiple attempts, and another resident with severe cognitive impairment left through sliding doors unnoticed. A resident with an anti-elopement alarm on her wheelchair repeatedly triggered the door alarm throughout the day, yet staff did not effectively respond, allowing her to exit unsupervised and fall on stairs, sustaining minor injuries.
The facility failed to provide meaningful, resident-centered activities for multiple dementia residents in the memory care unit, resulting in individuals sitting idle in dining and common areas, staring at blank or inappropriate televisions, sleeping in chairs, or wandering hallways without engagement. Activity sessions were canceled or not implemented as scheduled, and when paper activities like word searches were offered, only a few residents participated while others received no assistance, including a resident who repeatedly requested glasses and another who did not speak English. Sitters did not help residents with activities, and an activity staff member spent time on a computer and left the unit for other duties. Staff interviews revealed that management directed the limitation of music and physical activities, that residents were often left in bed because it was easier for staff, that floor staff did not conduct activities in the absence of the activity staff, and that the posted activity calendar, which included exercise, trivia, book club, and weekend "Resident Choice Day," was frequently not followed despite a policy requiring meaningful activities tailored to dementia residents.
A hospice resident with metastatic cancer and behavioral symptoms received multiple sedating medications, including quetiapine, hydrocodone, morphine, lorazepam, olanzapine, and prednisone, without thorough assessment for unnecessary drugs, duplicate therapy, or adverse consequences. Despite documented behavioral issues, falls, cognitive decline, and moderate to severe pain scores, staff reported no concerns with the medication regimen. The resident became increasingly sedated, was found unconscious with minimal response to painful stimuli, and was sent to the hospital, where documentation linked the clinical picture to disease progression and medication effects, including opioid use and possible steroid-induced psychosis.
A resident with a documented history of opioid-induced constipation and prior fecal impaction was admitted from the hospital, where providers had noted difficulty balancing opioid use and constipation medications. On admission, facility documentation characterized the resident as having normal stool and rarely needing laxatives. Over the following weeks, bowel records showed multiple days without a bowel movement, yet the MAR reflected no scheduled or PRN constipation medications given. Nursing notes documented no constipation despite absent bowel sounds, while subsequent hospital imaging revealed an extensive rectal stool burden concerning for stercoral colitis. Staff interviews confirmed that the prolonged absence of bowel movements was not reported, the resident received no PRN bowel medications, and there was no specific bowel and bladder management policy.
Staff failed to follow hand hygiene practices while caring for a resident with weeping, hot lower legs who had been started on antibiotics for cellulitis. One staff member removed TED hose from the resident’s weeping left leg and then immediately assessed the right leg without changing gloves or performing hand hygiene. Another staff member, after applying TED hose to the weeping leg while gloved, continued to handle the resident’s food, pillow, and personal items and answered a cell phone by placing her gloved hand into her pocket, all without changing gloves or performing hand hygiene, contrary to the facility’s hand hygiene policy.
The facility failed to protect residents from abuse when one resident without capacity to consent was found in a common area with another resident’s hand inside her brief, and the subsequent investigation did not include interviewing or assessing other residents who might have been affected. In a separate event, a resident shook his spouse’s head and later sprayed water in her face with a spray bottle when she was tired at dinner, causing her agitation, while both continued to share a room and she spent most of her time and slept in common areas due to ongoing behaviors between them, as reflected in her care plan.
Failure to Prevent and Manage Pressure Ulcer Leading to Severe Sacral Wound
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate prevention and treatment of pressure ulcers and to complete and document required skin and wound assessments for a dependent resident. The resident was admitted from a hospital with red skin on the right elbow, a left neck surgical laminectomy site, and a left shin abrasion, and was totally dependent on staff for bed mobility, transfers, dressing, toileting, personal hygiene, and bathing, and had a Foley catheter. Within six days of admission, weekly wound documentation showed the resident had developed bilateral buttock moisture-associated skin damage (MASD) of significant size. The resident was then hospitalized for confusion and hyponatremia, and hospital wound care documented a deep tissue pressure injury to the sacrum that evolved into a Stage III pressure injury with yeast. When the resident returned to the facility, the facility’s readmit screener documented MASD to the buttocks and a yeast rash to the buttocks and groin, but no sacral pressure injury. Subsequent facility wound documentation showed that a few days after readmission, the resident had scattered ulcerations with MASD to the buttocks and a Stage III pressure ulcer to the right medial lower buttock, and that orders for treatment were requested from the physician. By the following week, the weekly wound observation tool documented that the Stage III bilateral buttock wounds had merged into one large unstageable pressure ulcer with odor and moderate purulent drainage, indicating potential infection. During this same period, there were no documented skin/wound assessments for the week leading up to the resident’s transfer back to the hospital, and a staff member later stated she did not know where the assessments were or why they were not done, and could not explain why no one reported that the wound was worsening. The care plan listed multiple skin integrity problems and interventions, including skin evaluations, routine turning and repositioning, CNA skin inspections with routine care, monitoring nutrition, and weekly nurse skin evaluations, but did not specify task frequency for some interventions. Interviews further described staff awareness and handling of the resident’s condition and behaviors. A family member reported that staff were frequently frustrated by the resident’s constant need for attention and anxiety, and that he repeatedly educated management about the resident’s high anxiety and hyperfocus, and did not understand how staff could report spending so much time with the resident yet not recognize how sick he was with infection. A staff member stated the sacral wound was facility-acquired, that the resident became obtunded related to opioids, and that she was unaware of the resident’s excessive water intake until after a hospital stay. Another staff member who completed a readmission history and physical found the resident febrile, with therapy unable to mobilize him due to pain, and described the resident as heavily sedated on an intense pain regimen that predated his stay. This staff member stated there were many opportunities for improvement in nursing assessments and that the facility could not handle the resident’s complex psychiatric and pain needs. Ultimately, the resident was transferred to the hospital with a large sacral decubitus wound with purulent tissue, surrounding cellulitis, and radiologic evidence of a severe sacral ulcer with erosion nearly to the coccyx and associated abscess and necrotizing soft tissue infection.
Improper Labeling, Dating, and Handling of Refrigerated Food Items
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage practices when, during an observation of the walk-in cooler, multiple food items were found undated or unlabeled, contrary to the facility’s Food Safety Requirements policy. Specifically, two zip-lock bags of slimy, sliced tomatoes were not dated; a gallon zip-lock bag of ground meat was not labeled with the food type or date; and separate gallon zip-lock bags of sliced ham, sliced roast beef, and sliced cheese were all undated. In addition, a cup of sliced strawberries had no date. Staff interviews revealed that kitchen staff had observed mold on strawberries upon delivery and would usually attempt to pick out the molded strawberries, and another staff member acknowledged awareness of ongoing dating issues with refrigerated foods. A further interview indicated that moldy dinner rolls had been served on one occasion, prompting staff to retrieve the rolls from residents after service. The facility’s written policy required labeling, dating, and monitoring refrigerated food, including leftovers, so it would be used by its use-by date or frozen/discarded, but these requirements were not followed, placing all residents at risk for foodborne illnesses. No specific residents or their medical histories were identified in the report; the deficiency was described as affecting all residents through improper food labeling, dating, and handling practices in the kitchen and walk-in cooler.
Failure to Submit Abuse and Elopement Investigation Findings Within Required Timeframe
Penalty
Summary
The facility failed to submit investigation findings related to alleged abuse and elopement incidents to the State Survey Agency (SSA) within the required 5 working days for multiple residents. For one incident dated 1/24/26, a resident left her room and kicked another resident’s feet; the facility’s investigative findings for this event were not submitted to the SSA until 2/4/26, which was 11 days after the incident was reported. For another incident dated 3/20/26, one resident kicked another resident in the legs while both were in wheelchairs, with no injuries reported and immediate separation of the residents; review of records showed no evidence that the facility ever submitted investigative findings for this incident to the SSA. Additionally, review of the SSA reporting site showed that the facility made initial reports of elopement for a resident on 7/18/25 and 2/1/26 but did not submit final investigation reports within the required 5 working days. There were no final reports for either elopement incident. During an interview, a staff member stated that another staff member, who was out of the facility during the survey week, was responsible for reporting and submitting investigative findings to the SSA for abuse allegations. The same staff member confirmed the expectation that findings of any abuse allegation be reported to the SSA within 5 working days and acknowledged they could not provide investigative findings for the 3/20/26 incident. The facility’s written policy, reviewed and dated 7/15/25, required that results of all investigations of alleged violations be reported within 5 working days of the incident.
Failure to Investigate Resident Abuse and Elopements or Identify Root Causes
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and manage an allegation of resident-to-resident abuse and multiple resident elopements. In one incident, a resident in a wheelchair kicked another resident multiple times in the lower legs while both were at the nurses’ station. Nursing documentation noted the kicking and that there were no injuries, and the immediate response was to separate the residents. However, review of the facility’s abuse investigations for the relevant period showed no completed investigation related to this reported allegation of resident-to-resident abuse, and there was no documentation of investigative findings or that these findings were reported to the State Survey Agency. The facility also failed to protect the involved residents from further potential abuse. Nursing notes for both residents documented that, two days after the kicking incident, one resident was observed continually attempting to follow, communicate with, agitate, and argue with the other resident, and staff had to separate them twice. Staff communicated to others to monitor their interactions, but the notes showed that the residents continued to have problematic contact, indicating that the facility did not prevent further potential abuse between them. During interview, a staff member stated that another staff person was responsible for investigating and reporting abuse allegations, but that person was unavailable and no documentation could be produced to verify that an investigation had been completed or that results were reported to the state agency, despite facility policy requiring thorough investigation, protection of residents during the investigation, and reporting of results. The deficiency also includes failures related to multiple elopements by several residents. For one resident, an elopement investigation documented that the resident exited the facility, but the investigation lacked signatures, identification of information sources, and clear involvement of the email sender included in the file. A state abuse reporting entry indicated that this resident left through back doors, possibly following a volunteer or staff taking other residents to Mass, and was brought back by a Med-Surg nurse, but there was no documented root-cause analysis or explanation of why the elopement occurred or what interventions were implemented to prevent recurrence. Another resident eloped through doors leading into the hospital; the reportable incident was submitted to the SSA, but there were no nurses’ notes on the date of the elopement describing the event, and a note the following day only stated that the resident attempted to elope twice, reflecting incomplete contemporaneous documentation. For this same resident, the facility’s investigation of the elopement included only limited staff interviews and did not include interviews with CNAs or activity staff to establish a full timeline of the resident’s movements or to identify the root cause. A subsequent elopement by this resident into the hospital was documented in a nursing note, and the investigation consisted of an undated handwritten note stating that people came into the unit looking for someone in the hospital, left to go to Med-Surg, and the resident followed them out the door, with the door alarm functioning and the resident returning to the unit. There was no documented timeline, no detailed interviews, and no analysis of the effectiveness of elopement-prevention interventions. A third resident had multiple documented elopements over several months, with investigation files that often contained only brief summaries, incomplete checklists, or limited supporting documents such as bounds reports or invoices for a wander guard system. Across these events, the facility did not consistently document root-cause analyses or assessments of the resident’s exit-seeking behavior, and the record notes that this failure to identify and document root causes led to a fall with injury for this resident. Interviews with staff confirmed that the facility’s practice did not align with its stated expectations. One staff member reported that a former staff person had previously conducted incident investigations but had left months earlier, and that the expectation for investigations was to determine the root cause of incidents and monitor residents to ensure interventions were implemented. Another staff member stated that after each elopement, the nurse would file a report to the SSA and update the care plan, after which management was supposed to conduct a full investigation. A further interview indicated that nurses entered occurrence reports and submitted SSA reports to track elopements and that staff discussed root causes but did not maintain documentation of those analyses. These statements, combined with the incomplete and inconsistent investigation records, demonstrate that the facility did not carry out or document thorough investigations, root-cause analyses, or protective measures as required by its own abuse investigation and reporting policy.
Failure to Prevent Elopements and Respond to Anti-Wandering Alarms
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and effective interventions to prevent elopements for multiple residents identified as at risk for wandering, despite existing assessments and care plans. Staff reported that residents at risk for elopement were identified by the MDS nurse on admission and quarterly, and that anti-wandering devices and door alarms were in place, particularly at the front door. However, staff also indicated that wander guard bracelets could be applied without formal assessment, and that information about elopement risk was communicated via paper “brain” sheets. The facility had a written SBAR and procedure for anti-wandering door alarms, including immediate resident location checks and following an elopement procedure, but the report shows these processes were not effectively implemented. One resident with a documented elopement risk and dementia was care planned to have an anti-wander device on her wheelchair and to be involved in activities and redirected when she attempted to exit. She eloped on at least two occasions: once when she went through the first set of doors and was found in a corridor by another resident, and another time when she exited through back doors, apparently following others going to Mass, with no alarms triggered. Her care plan documentation was inaccurate regarding the presence of a wander guard door in 2024, and there was no nursing documentation of the February elopement in her electronic health record. Another resident with severe cognitive impairment (BIMS score of 3) and an elopement risk care plan that included redirection, diversional activities, and ensuring door alarms were activated, was able to get out between the sliding front doors when someone was entering or exiting, and no one saw her leave, contrary to the care plan interventions. A further resident with dementia and short-term memory problems was identified as at risk for elopement, yet his elopement care plan and interventions were not initiated until after he had already eloped twice in one afternoon through different doors. He later eloped again, but the corresponding nursing note was not provided. Another resident, described as exit seeking and very independent with behavioral issues toward staff, had an anti-elopement alarm device on her wheelchair that sounded as she approached the door and had been near the door setting off the alarm throughout the day. Despite this, she was able to push open the main entrance sliding doors, exit, and then fall while attempting to walk down stairs, sustaining an abrasion and bruising and requiring hospital evaluation. Staff interviews indicated that interventions such as 1:1 monitoring, taking her outside, and diversional tasks were used, and that elopements were tracked via occurrence reports and state submissions, but the facility failed to identify the need for continuous one-on-one monitoring for this resident, failed to respond appropriately to the anti-elopement door alarm, and failed to prevent her unsupervised exit and subsequent fall. Activity staff also reported that, after a staffing reduction, there were no organized activities after 5 p.m., despite prior recognition that increased monitoring and activities during late afternoon hours were needed for an elopement-risk resident.
Failure to Provide Meaningful Activities for Dementia Residents in Memory Care Unit
Penalty
Summary
The deficiency involves the facility’s failure to provide meaningful, resident-centered activities to meet the needs of multiple residents with dementia in the memory care unit. Surveyors observed residents sitting in dining and common areas without any activities, including a resident with a BIMS score of 0 repeatedly scratching her arms while staring at a turned-off television, and another resident wandering the unit and running into walls. On another observation, the scheduled activities were canceled due to weather, and the activity staff member present was working on care plans on a computer while residents sat with newsletters in front of them, many staring at the floor or sleeping. Only some residents participated in the offered activities, while others, including residents with severely and moderately impaired memory, did not participate and were not engaged. During the same observation period, residents were given a word search activity, but only a few actively worked on it. Sitters, who were present to watch and redirect residents, sat at the tables and did not attempt to assist residents with the activity. One resident repeatedly stated she needed her glasses to see the paper, but no staff obtained her glasses. A resident who did not speak English sat staring down the hall without engagement, and another resident with severe cognitive impairment wandered the hall. The activity staff member stated she had other duties in another unit and left, and later that evening, surveyors observed one resident sleeping in a recliner and another staring at a wall while cartoons played on the television. Interviews with staff revealed that activities in the memory care unit were limited and often not implemented as scheduled. The activity staff member reported she was instructed by management to avoid music and physical activities because staff believed these would cause residents to become agitated, and that she was told to limit activities to calming options only. She also stated that residents were often left in bed and not taken to activities because it was easier for staff, and that floor staff did not provide activities when she was not present, preferring residents to sit quietly. Other staff confirmed that activities usually did not occur in the memory care unit, that activities observed during the survey were a show for surveyors, and that the activity calendar was not followed. The memory care activity calendar showed “Resident Choice Day” on all weekends and listed trivia, exercise/stretching, and book club on weekdays, while the facility’s activities policy required activities to enhance well-being, physical activity, cognition, and to provide meaningful activities for residents with dementia.
Failure to Assess Hospice Resident’s Polypharmacy and Sedation Risk
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s drug regimen was free from unnecessary medications and thoroughly assessed for sedation, duplicate therapy, and adverse consequences. A hospice resident with metastatic cancer, delirium, psychosis, and impulsive, intermittently aggressive behavior was receiving multiple medications including antipsychotics, opioids, benzodiazepines, and a steroid. Hospice staff discontinued some medications and added morphine and lorazepam, while the resident also continued on quetiapine, hydrocodone, prednisone, and later received a one-time dose of olanzapine. Facility staff A and B reported that they had no concerns with the resident’s medications despite the combination of psychotropic and sedating drugs. The resident had been ambulatory on arrival to the facility but became weaker with multiple falls, nonsensical and incoherent speech, and combative and unsafe behavior. One-to-one supervision was initiated due to impulsivity and aggression, and staff questioned whether pain contributed to the aggressive behavior. The resident’s pain scores documented on the Medication Administration Record over three days showed moderate to severe pain levels (5/10, 3/10, and 7/10), while the resident continued to receive multiple sedating medications, including quetiapine every eight hours, hydrocodone three times daily, lorazepam as needed every four hours, morphine as needed every four hours, and prednisone daily. On the day before transfer to the hospital, the resident received olanzapine, prednisone, hydrocodone, two doses of lorazepam, and morphine; on the day of transfer, the resident received lorazepam, morphine, and prednisone. When a family member arrived at the facility, they found the resident unconscious with minimal response to painful stimuli and appearing sedated, and they requested transfer to the hospital. The family reported the resident had been more sedated at the facility lately, and the emergency room provider reportedly told the family the resident had an overdose of medications. Hospital documentation noted altered mental status, hypoxia, and that the resident’s dementia and chronic encephalopathy may have been exacerbated by disease progression and opioid use, possible steroid-induced psychosis, and electrolyte imbalance. The facility did not identify or address the resident’s medication regimen as a contributing factor to sedation or assess for duplicate therapy and adverse consequences prior to the resident’s transfer.
Failure to Monitor and Treat Constipation in Resident With Opioid-Induced Constipation History
Penalty
Summary
The facility failed to monitor and manage constipation for a resident with a known history of opioid-induced constipation and prior use of constipation medications. Hospital records showed the resident had been admitted with a 9.6 cm fecal impaction and that the hospital physician documented the resident could go up to five days without a bowel movement, likely due to opioid use, and was working on balancing opioid-induced constipation with constipation medications. Upon admission to the facility, the Admit/Readmit Screener documented that the resident had normal formed stool and rarely or never depended on laxatives, despite this history. Facility bowel documentation later showed gaps in bowel movements, including no bowel movement for several days. Review of the Medication Administration Record for March and April showed the resident did not receive any scheduled or PRN constipation medications during the stay. Bowel documentation indicated no bowel movement from 3/29 to 4/3, followed by diarrhea on 4/4 and a putty-like stool on 4/5. A nursing progress note on 4/6 documented a flat, non-tender abdomen with no bowel sounds and no constipation, while hospital records from the same date, after readmission, showed an extensive stool burden distending the rectum to 8.8 cm with findings concerning for stercoral colitis. Staff interviews revealed that no one reported the resident had gone six days without a bowel movement, the resident had gone without any PRN bowel medications, and the facility did not have a policy specific to bowel and bladder management.
Failure to Perform Hand Hygiene During Wound and Skin Care
Penalty
Summary
Facility staff failed to ensure proper hand hygiene during care of a resident with suspected infected lower extremities. During an observation, two staff members entered the room of a resident who had reported weeping and hot lower legs. One staff member removed the TED hose from the resident’s left leg, noted that the leg was hot to the touch and weeping edema fluid, then moved directly to the right leg, removed the TED hose, and assessed that leg without changing gloves or performing hand hygiene between contact with the weeping left leg and the intact right leg. This same staff member later stated she believed she had completed all hand hygiene opportunities but realized, when questioned, that she had moved from one leg to the other without performing hand hygiene. The resident had been started on Cipro for cellulitis on the morning of the observation. A second staff member returned to the room with new TED hose and socks, donned gloves, and assisted with applying the TED hose. This staff member applied TED hose to the resident’s left leg, observed weeping fluid from the skin, and then proceeded to clean up the room while still wearing the same contaminated gloves. While gloved, she touched the resident’s food on the bedside table, handled the resident’s pillow and placed it on the chair where the resident was sitting, and put her gloved hand into her clothing pocket to turn off her ringing cell phone. She did not perform hand hygiene or change gloves after contact with bodily fluids and before touching other items in the room. After leaving the room, she stated she had not thought about performing hand hygiene after finishing application of the TED hose. The facility’s hand hygiene policy required hand hygiene after handling contaminated objects, when moving from a contaminated site to a clean body site during resident care, and after handling items potentially contaminated with blood or bodily fluids.
Failure to Protect Residents From Sexual and Physical Abuse by Other Residents
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from abuse, including sexual and physical abuse, by other residents. In one incident, a resident without capacity to consent was found in a common area with another resident’s hand inside her brief up to the wrist. Staff immediately separated the residents, and the incident was reported to the State Survey Agency; however, the facility’s investigation did not include interviewing or assessing other residents who might have been present or potentially affected by similar sexual abuse incidents. A staff member also reported that the incident was initially reported under the wrong license type because they were unaware the facility held both an adult day care and a skilled nursing facility license. In a separate incident, a resident became upset with his spouse, also a resident, during dinner and shook her head to wake her, then later sprayed water in her face with a spray bottle after staff had intervened and moved her to the nurses’ station. The spouse became agitated by these actions. Observations showed that the couple continued to share a room, with both residents’ nameplates and belongings present. Staff interviews indicated that the spouse who was the target of the behavior was usually kept out of the room and spent most of her time and slept in common areas or by the nurses’ station due to ongoing behaviors between the two. The care plan for the spouse reflected that she was not to be in the room when her husband was present unless both wanted to be there, and staff were to intervene if yelling occurred, based on the prior incident of head shaking and use of the spray bottle.
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