The Valley Health And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Hamilton, Montana.
- Location
- 601 N 10th St, Hamilton, Montana 59840
- CMS Provider Number
- 275135
- Inspections on file
- 21
- Latest survey
- April 23, 2026
- Citations (last 12 mo.)
- 29
Citation history
Health deficiencies cited at The Valley Health And Rehab during CMS and state inspections, most recent first.
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 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 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 serve lunch at its scheduled times, with trays on one unit being delivered 36–47 minutes late on multiple days, despite a written schedule specifying earlier service. A resident on that unit experienced repeated delays, with a family member reporting that meals were often late and that the resident was not allowed to lie down until after lunch, causing frustration when lunch arrived significantly behind schedule and was then refused. Staff interviews confirmed that meals had been running late more frequently, citing short staffing in the kitchen, training of a new cook, and the time required to dish up and pass trays, in contrast to the facility’s policy requiring three daily meals without extensive time lapses.
Surveyors identified a failure to store food according to professional standards when they observed multiple open and prepared food items in the walk-in freezer and refrigerator without labels or dates, including an open bag of French fries, cut tomatoes and onion wrapped in cellophane, and a half-empty pan of red Jello. The dietary supervisor reported that staff are instructed to check received and expiration dates, label and date all open and cut items, and use a posted "Use by Date Guide" as a reminder, and facility policy requires labeling, dating, monitoring refrigerated foods, and keeping foods covered or in tight containers.
Insufficient staffing on the Memory Care Unit resulted in residents not receiving needed ADL care, supervision, and meal assistance. Staff reported being unable to complete required tasks, often skipping baths and showers, and residents were observed unkempt and without proper support. Facility records confirmed multiple days with staffing below assessed needs, directly impacting resident care and safety.
A staff member was found to have engaged in verbally abusive behavior toward vulnerable residents in a secure memory care unit, as reported by another employee and confirmed through interviews. The incident involved yelling at residents during a night shift, with prior negative verbal interactions also substantiated. Residents were assessed for distress following the event, but no acute distress was observed.
Ten residents who required assistance with ADLs did not receive regular showers or adequate hygiene support, as evidenced by observations of unkempt appearance, resident and family complaints, and gaps in shower logs. Residents with conditions such as decreased mobility, Parkinson's disease, and stroke were not consistently assisted with bathing as outlined in their care plans, and facility documentation showed missed or delayed showers despite identified concerns.
The facility did not complete thorough investigations into staff-to-resident verbal abuse and neglect allegations involving two residents, failing to monitor residents, implement documented interventions, or interview other residents and staff. Documentation was incomplete for multiple incidents, and required investigative steps were not followed according to facility policy.
A resident with Alzheimer's disease and severe cognitive impairment exhibited frequent distress, behavioral symptoms, and functional decline. Staff did not implement care-planned interventions such as diversional activities, one-to-one support, or prompt redirection, and failed to provide adequate supervision or monitor interactions with others. Documentation showed minimal activity participation and incomplete mood and behavior assessments, despite the resident's ongoing distress and behavioral issues.
Staff did not consistently use Enhanced Barrier Precautions (EBP) or appropriate PPE when providing high-contact care to two residents with urinary catheters. In both cases, staff either failed to don PPE or only wore gloves despite clear facility policy and signage requiring EBP for residents with indwelling devices during transfers and toileting.
A resident was transferred or discharged without the facility ensuring that their needs and preferences were met, and without adequate preparation for a safe transition.
The facility did not complete a thorough investigation after a staff member was witnessed verbally abusing a resident. Required 72-hour monitoring and emotional support for the affected resident were not documented, and no additional resident interviews were conducted to rule out further abuse concerns, contrary to facility policy.
A resident at risk for nutritional deficits experienced severe weight loss due to inadequate monitoring by the facility. Despite being identified as at risk due to recent weight loss and comorbidities, the resident's weight was not recorded for over a month, resulting in a 25.5-pound loss. The facility's policy required weekly weights for such residents, which was not followed.
The facility failed to maintain safe and palatable food temperatures for residents eating in their rooms. A resident reported receiving cold food, and another mentioned a specific instance of a cold taco. Staff confirmed that food was not kept at the required temperature, with a pancake served at only 100.7°F, below the mandated 135°F. The facility's policy requires hot food to be served at a minimum of 135°F, which was not followed.
A facility failed to ensure a POLST form for a resident was completed with the necessary signature from the resident or their decision-maker. The POLST form, which indicated preferences such as DNR and comfort measures only, lacked a documented signature or printed name. Facility policy requires that advance directives and POLST forms be documented and reviewed, but this was not adhered to in this case.
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 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 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.
Late Meal Service and Resident Frustration Due to Delayed Lunch Trays
Penalty
Summary
The deficiency involves the facility’s failure to provide meals at the scheduled times established by its own meal schedule, resulting in resident frustration. The facility’s posted meal schedule indicated that lunch trays for Birch Hall residents were to be delivered at 12:20 p.m. However, observations on two separate days showed that lunch trays were passed significantly later than scheduled: at 12:56 p.m. on one day (36 minutes late) and at 1:07 p.m. on another day (47 minutes late). On one of these days, the last lunch tray to Birch Hall was still being delivered at 1:14 p.m. Staff interviews confirmed that meals were sometimes late, that residents often sat waiting in the dining room for extended periods, and that meals had been served late more frequently recently. One resident, identified as resident #31, was directly affected by these delays. On one day, the resident’s lunch tray was delivered to his room at 12:56 p.m., and a family member (NF1) reported that lunch meals were often served late and that “you get used to it over time.” On another day, NF1 approached staff to ask where the lunch meal was, stating that the resident wanted to lie down but had been told he could not do so until after lunch, and that he was not happy lunch was so late. When the tray was finally delivered at 1:07 p.m., the resident expressed dissatisfaction with the meal, and NF1 returned the tray and ordered an alternative. Staff interviews attributed the late meals to factors such as training a new cook, being short two kitchen staff members, and the time it took staff to dish up and pass the meals, despite a facility policy stating that residents would receive at least three meals daily without extensive time lapses between meals.
Failure to Label and Date Open and Prepared Food Items in Dietary Storage
Penalty
Summary
Surveyors found that the facility failed to store food in a sanitary manner in the dietary department. During an observation of the walk-in coolers, an open bag of French fries was found in the freezer with no label or date. In the refrigerator, two halves of a tomato wrapped in cellophane, half of an onion wrapped in cellophane, and a large pan of half-empty red Jello were also observed without any labels or dates. These items were not labeled or dated as required by facility policy. In an interview, the dietary staff member responsible for directing dietary staff stated that she instructs staff to check the received date and expiration date when they open an item and to place a label and date on any open items and anything cut and wrapped in cellophane. She reported that she continues to remind staff to label open items and indicated that a "Use by Date Guide" was posted on the outside of the refrigerator door as a reminder of the rules for dating open items. Review of the facility’s Food Safety Requirements policy confirmed that food is to be stored in accordance with professional standards, including labeling, dating, and monitoring refrigerated food such as leftovers so it is used by its use-by date or discarded, and keeping foods covered or in tight containers.
Insufficient Staffing Leads to Inadequate Resident Care and Supervision
Penalty
Summary
The facility failed to provide sufficient nursing staff on the Memory Care Unit to meet the needs of residents, resulting in inadequate monitoring, assistance with activities of daily living (ADLs), meal assistance, and abuse prevention. Multiple observations and staff interviews revealed that residents were left unsupervised, including those requiring one-to-one supervision due to disruptive behaviors. Staff reported being unable to complete all required tasks during their shifts, often skipping baths and showers due to time constraints and insufficient staffing. Residents were observed wearing the same clothing over consecutive days, appearing unkempt, and not receiving scheduled or needed bathing services. Further observations documented residents without appropriate assistance during meals, such as a resident eating with her fingers and pouring water onto her plate without staff intervention. Staff consistently reported that the lack of adequate staffing made it difficult to provide necessary care, particularly for bathing and supervision. The facility's own records confirmed that on several days, staffing levels were below what was identified as necessary in the facility assessment, directly impacting the quality of care provided to residents. Documentation and interviews indicated that the facility had identified staffing as an ongoing issue, particularly affecting the provision of ADL care and resident supervision. The lack of staff also affected the ability to provide activities and ensure resident safety, with staff expressing concerns about their inability to protect residents and complete essential care tasks. The deficiency was supported by observations, interviews, and record reviews, all indicating a pattern of insufficient staffing leading to unmet resident needs.
Verbal Abuse of Vulnerable Residents in Memory Care Unit
Penalty
Summary
A staff member on the memory care unit was reported to have engaged in verbally abusive behavior toward residents. The incident was initially brought to attention when a CNA reported, via text message, that an employee had been yelling at residents during the night shift. The report did not specify which residents were involved or the exact language used, but all residents in the memory care unit were identified as vulnerable. Subsequent interviews confirmed that the staff member in question had previously demonstrated negative verbal interactions with residents. The facility's investigation substantiated the allegation of verbal abuse, confirming that the staff member had engaged in inappropriate verbal conduct toward residents on more than one occasion. At the time of the incident, residents were assessed for signs of distress or behavioral changes, but no acute distress was noted. The deficiency centers on the occurrence of verbal abuse directed at vulnerable residents in the secure memory care unit by a staff member.
Failure to Provide Regular Showers and ADL Assistance
Penalty
Summary
The facility failed to provide regular showers and adequate assistance with activities of daily living (ADLs) for 10 out of 18 sampled residents who were unable to perform these tasks independently. Observations and interviews revealed that multiple residents appeared unkempt, with oily or matted hair, and expressed feelings of being dirty or neglected due to missed or infrequent bathing. Shower logs confirmed significant gaps between baths, with some residents going up to 16 days or more without a shower, and in one case, a resident did not receive any bath in a 30-day period. Residents' care plans consistently indicated the need for staff assistance with bathing due to various medical conditions such as decreased mobility, Parkinson's disease, stroke, and memory deficits. Several residents and their families reported concerns about hygiene and the lack of regular bathing. For example, one resident stated that staff refused to help with baths, resulting in missed showers and feelings of being dirty. Another resident's family contacted the facility to express concern about the resident's matted hair and infrequent bathing. Residents' care plans outlined specific interventions, such as offering bed baths if showers were declined and notifying nursing staff if both were refused, but documentation and interviews indicated these interventions were not consistently implemented. A review of the facility's Quality Assurance and Performance Improvement (QAPI) Performance Improvement Project (PIP) action plan identified issues with staffing, adherence to bathing schedules, and documentation as root causes for the deficiency. Despite recognizing the problem, the facility did not follow through with corrective actions, as evidenced by ongoing missed or delayed showers for multiple residents. Facility policy required that care and services for ADLs, including bathing, be provided based on comprehensive assessment and resident needs, but this standard was not met for the affected residents.
Failure to Complete Thorough Abuse and Neglect Investigations
Penalty
Summary
The facility failed to conduct thorough investigations into allegations of staff-to-resident verbal abuse and neglect involving two residents. Specifically, the facility did not complete resident monitoring, did not implement interventions that were identified and documented in the incident reports, and did not interview other residents to determine if additional individuals were affected. Documentation for several incidents was incomplete, lacking summaries, evidence of staff education, and records of monitoring activities such as bathing logs or audits. Interviews with staff revealed that investigation folders had not been fully reviewed and that the investigations were still in progress, despite being part of a plan of correction from a previous complaint survey. The facility's own policy requires comprehensive investigation procedures, including reporting, analysis, staff training, and monitoring, but these steps were not documented or carried out as required for the incidents in question.
Failure to Implement Dementia Care Interventions and Supervision
Penalty
Summary
The facility failed to provide appropriate services, treatment, and interventions for a resident diagnosed with Alzheimer's disease and dementia, who exhibited significant cognitive and functional decline. The resident displayed frequent physical and verbal behaviors, including crying, yelling, wandering, and making statements indicating pain, fear, and distress. Despite these behaviors, staff did not implement the care-planned interventions such as providing diversional activities, one-to-one support, or prompt redirection when the resident was upset. Observations showed the resident calling out for help, expressing fear, and making statements about not wanting to live, without staff intervention or support. Interviews with staff revealed that the resident required constant supervision and had a history of altercations with other residents. Staff acknowledged that there was insufficient supervision and that activities for dementia care were lacking or only recently initiated. Documentation showed that the resident participated in very few activities over a two-month period, despite care plan interventions specifying the need for engagement in activities of interest and avoidance of overstimulation. Staff also failed to monitor and intervene during verbal altercations between residents, as required by the care plan. Review of the resident's health records and Minimum Data Set (MDS) assessments indicated severe cognitive impairment, increased behavioral symptoms, and a decline in functional abilities. The resident was unable to complete mood interviews, and staff assessments were either incomplete or blank. The care plan identified the resident as being at risk for verbal abuse from others due to her behaviors, yet the documented interventions were not consistently implemented, resulting in unaddressed distress and behavioral symptoms.
Failure to Implement Enhanced Barrier Precautions for Residents with Catheters
Penalty
Summary
Staff failed to consistently implement Enhanced Barrier Precautions (EBP) for residents with indwelling urinary catheters, as required by facility policy. During observations, one staff member was seen leaving a resident's room after assisting with a transfer using a mechanical lift, without donning any personal protective equipment (PPE). The resident had a catheter in place, and there was no PPE caddy available outside the room. The staff member admitted to not using PPE and stated she intended to retrieve supplies afterward. The resident confirmed that PPE was not always used during catheter care and noted that PPE supplies had previously been available but were removed, leading to more relaxed practices among staff. In another instance, a staff member entered a different resident's room, which had signage and a PPE caddy indicating the need for EBP, but did not don PPE before assisting the resident, who also had a catheter, with a transfer to the toilet. The staff member only wore gloves and stated she had just been informed that day about the requirement for PPE use with catheters. Interviews with other staff confirmed that EBP should be used for residents with wounds, catheters, or multidrug-resistant organisms during high-contact care tasks, such as transferring and toileting. Review of the facility's policy confirmed these requirements, but observations and interviews demonstrated inconsistent adherence.
Failure to Ensure Safe and Resident-Centered Transfer/Discharge
Penalty
Summary
The facility failed to ensure that the transfer or discharge process met the resident's needs and preferences, and did not adequately prepare the resident for a safe transfer or discharge. This deficiency was identified based on observations and documentation showing that the necessary steps to assess and address the resident's individual requirements and preferences during the transfer or discharge process were not completed. As a result, the resident was not fully prepared for a safe transition to the next care setting.
Failure to Complete Thorough Abuse Investigation and Resident Monitoring
Penalty
Summary
The facility failed to conduct a thorough investigation following an incident of staff-to-resident verbal abuse witnessed by several management staff. Although the staff member involved was immediately removed from the facility, the investigation documentation indicated that the resident was to be placed on every-shift monitoring for 72 hours and provided with one-on-one emotional support. However, review of the resident's nursing progress notes, Medication Administration Record (MAR), and Treatment Administration Record (TAR) for the 72 hours after the incident revealed only a single progress note two days post-incident, which described the resident as somnolent and refusing some care, with no interventions noted for these behavioral changes. There was no documentation of the required monitoring or emotional support, and the MAR and TAR did not reflect the monitoring order. Additionally, the facility did not conduct interviews or assessments with other residents to determine if there were further concerns of abuse by the same staff member, as required by facility policy. Staff interviews confirmed that no additional resident interviews were performed, and all investigation materials were limited to the file provided. The facility's policy mandates identifying and interviewing all involved persons and providing emotional support to affected residents, but these steps were not completed in this case.
Failure to Monitor Resident's Weight Leads to Severe Weight Loss
Penalty
Summary
The facility failed to adequately monitor a resident at risk for nutritional deficits, leading to severe weight loss. A staff member indicated that CNAs were responsible for checking the EHR to determine which residents needed to be weighed, with varying frequencies such as monthly, weekly, or daily. However, there was a lapse in monitoring as the resident did not have weights recorded from late September to early November, during which time the resident experienced a significant weight loss of 25.5 pounds. The resident, who was already at risk due to recent weight loss, inadequate food intake, and comorbidities including wounds, was not weighed according to the facility's policy for residents with weight loss, which required weekly monitoring. The resident expressed concerns about his weight loss and mentioned that he had only recently started receiving daily weights to assess the need for a medication that increased urination. Despite the resident's thin appearance and his report of weight loss, the facility did not ensure consistent weight monitoring. A staff member acknowledged the oversight in obtaining regular weights and noted that the resident's nutrition assessment was updated in November, but by then, the resident had already experienced severe weight loss. The facility's policy required weekly weights for residents with weight loss, which was not adhered to in this case.
Failure to Maintain Safe Food Temperatures
Penalty
Summary
The facility failed to maintain safe and palatable temperatures for food served to residents in their rooms, affecting three of the nineteen sampled residents. Resident #18 reported that their food was cold upon arrival in their room. Resident #3, who ate all meals in their room, also complained about the food being cold and unappetizing, mentioning a specific instance where a taco was served cold. Resident #13, who ate meals both in their room and the dining room, stated that breakfast served in their room was not warm enough. These residents expressed dissatisfaction with the temperature and quality of the food served. Observations and interviews with staff revealed that food was cooked and held at 135 degrees Fahrenheit in a steam table before being served. However, meals for residents eating in their rooms were left in the steam table until after dining room meals were served, leading to a delay. Staff member F confirmed that the temperature of a pancake served to resident #18 was only 100.7 degrees Fahrenheit, below the required 135 degrees Fahrenheit. The facility's policy mandates that hot food items must be cooked, held, and served at a minimum of 135 degrees Fahrenheit, which was not adhered to in these instances.
Incomplete POLST Form Lacks Required Signature
Penalty
Summary
The facility failed to ensure that a POLST form for one of the sampled residents was completed with the necessary signature from the resident or their decision-maker. During an interview, a staff member explained that residents or their representatives are asked about their advance directives upon admission, and these directives are reviewed during the initial care conference. However, a review of the electronic medical record for the resident in question revealed that the POLST form lacked a documented signature or printed name of the patient or decision-maker, despite indicating preferences such as DNR, comfort measures only, and no artificial nutrition by tube. The facility's policy requires that advance directives and POLST forms be documented in a prominent part of the resident's medical record and reviewed periodically. The policy also mandates staff training on these procedures. However, the resident's care plan and the facility's policy both emphasize the importance of having a signed POLST form, which was not adhered to in this case. The absence of a signature on the POLST form indicates a failure to comply with the facility's procedures and the legal requirements for validating such documents.
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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