Valle Vista Rehabilitation And Nursing Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Lewistown, Montana.
- Location
- 402 Summit Ave, Lewistown, Montana 59457
- CMS Provider Number
- 275021
- Inspections on file
- 20
- Latest survey
- November 21, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Valle Vista Rehabilitation And Nursing Llc during CMS and state inspections, most recent first.
A quadriplegic resident was transferred to another facility without being provided with a wheelchair, despite reliance on it for mobility, and arrived at the receiving facility without one. Additionally, the facility did not document the discharge in the medical record, omitting key information about the transfer and the resident's care.
Surveyors found that a common bathtub had not been cleaned for several months, with visible stains and sediment, and lacked signage indicating it was out of use. Staff confirmed the bathtub was not in use and believed monthly housekeeping audits were occurring, but no documentation of cleaning or audits was provided. Additionally, infection control policies, including water management and Legionella surveillance, had not been reviewed or updated annually as required.
The facility did not maintain complete medical records, as several residents lacked medical provider visit notes in both the EMR and paper charts, and a resident's POLST form was missing a required physician signature. Staff processes for handling provider notes were inconsistent, and the missing POLST signature was not identified during routine reviews.
Two residents were administered psychotropic medications, including antidepressants and antipsychotics, before informed consent was obtained from their representatives. In both cases, medication was started prior to the completion or documentation of consent, contrary to facility policy requiring consent before initiation. Staff interviews confirmed that the required process for obtaining consent was not followed.
Two residents with dementia received PRN antipsychotic medications without the required 14-day limitation or documented provider rationale for continued use. Medication regimen reviews did not address the ongoing use of these medications, and staff were unable to explain the oversight, despite facility policy requiring a 14-day limit for PRN antipsychotics.
A resident with encephalopathy and a conservator was suspected of being financially exploited when staff noticed unpaid bills and possible misuse of funds. Although APS was notified and an investigator assigned, the facility did not report the allegation to the state survey agency or document an internal investigation, contrary to its own policies.
A resident was transferred to the hospital on two occasions without receiving the required written notice explaining the reason for transfer. Staff confirmed that the transfer notices were not completed, and no documentation was found in the medical record or provided upon request, despite facility policy requiring such notification.
A resident with poor vision and limited hand function was not provided with a care plan that addressed her specific activity preferences or physical limitations. She reported spending most of her time in bed without being offered in-room activities or one-on-one visits, and the care plan lacked individualized interventions despite her needs and expressed interests.
A resident with poor vision and limited hand function did not receive group or individual activities to meet her interests or support her well-being. The resident reported no staff visits or in-room activities, and activity participation records showed no documented involvement since admission. The staff member responsible for activities acknowledged documentation issues and lack of time, and no supporting records or assessments were provided.
The facility failed to maintain a sanitary kitchen, affecting all residents consuming food from it. Observations revealed debris and dirt in various areas, and a dark brown substance at the floor's edge. Staff interviews indicated cleaning tasks were not consistently completed due to staff shortages and vacation. The facility's policy required regular cleaning, but checklists showed gaps in completion.
The facility lacked a certified director for food and nutrition services, affecting all residents receiving food. Staff member C, in the role for six months, had no training or oversight due to staff member G's absence. The dietician was only available by phone, and no dietary training documentation existed for staff member C.
The facility was found deficient in maintaining kitchen hygiene and food storage practices. Staff failed to wear required hairnets and beard nets, and several food items were improperly stored without labels or dates. The kitchen was unclean, with dirty equipment and missing laminate on cupboards. Dented cans were improperly stored, and staff admitted to neglecting proper procedures. The dietary manager's supervisor acknowledged a lack of oversight, contributing to these issues.
The facility was found to have expired medications and medical supplies in both the medication and treatment rooms. Items such as test strips, injection solutions, and various catheters were past their expiration dates. Staff acknowledged the oversight, and it was noted that the facility did not have a specific policy for handling expired items.
The facility failed to serve food at safe and appetizing temperatures, affecting three residents. Observations showed food items like eggs and hashbrowns were served below the required 135 degrees Fahrenheit. A resident expressed dissatisfaction with the consistently cold food, and staff acknowledged issues with the steam table and plate warmers. The facility's policy on maintaining hot food temperatures was not followed.
Failure to Provide Wheelchair and Proper Discharge Documentation
Penalty
Summary
A quadriplegic resident, who required a wheelchair for primary mobility due to spastic quadriplegic cerebral palsy, was discharged and transferred to an Adult Services Residential Program facility in Pennsylvania without being provided with a wheelchair. Interviews with staff revealed that although there was discussion about sending a manual wheelchair with the resident, there was no documentation confirming that a wheelchair was actually sent. The receiving facility reported that the resident arrived without any wheelchair, manual or electric, which was his main mode of locomotion. Additionally, the facility failed to document the transfer and discharge of the resident in the medical record. There was no discharge progress note on the day of discharge, and essential information such as a summary of the resident's stay, education on medications and treatments, a list of belongings, details of who picked up the resident, and the reason for discharge were missing. All discharge documentation was handled through email and TEAMS meetings rather than being properly recorded in the medical record as per facility policy.
Inadequate Infection Control Program and Equipment Cleaning
Penalty
Summary
The facility failed to maintain an adequate infection prevention and control program, as evidenced by improper cleaning and maintenance of resident-care equipment and lack of annual review of infection control policies. During an observation, a common bathtub in the North hallway was found with long streaks of dark, rust-colored stains and dried brown sediment around the drain. The bathtub lacked signage or a cover to indicate it was out of use. A staff member reported that the bathtub had not been cleaned in five or six months and confirmed it was not being used by residents, with only the toilet and sink in use in that bathroom. The staff member also believed that housekeeping audits were being conducted monthly by another staff member. Review of facility policies revealed that the cleaning and disinfection policy for resident-care equipment was last updated in April 2025, and both the Water Management Program Policy and Legionella Surveillance Policy had not been reviewed or revised since April 2020. The facility assessment indicated that routine maintenance and cleaning schedules existed for most equipment, with non-routine maintenance conducted as needed. However, when documentation was requested for cleaning or deep cleaning of the North hallway tub and for housekeeping audits from June 2024 to the present, no records were provided by the end of the survey.
Incomplete Medical Records and Missing POLST Signature
Penalty
Summary
The facility failed to maintain complete and accessible medical records for several residents, specifically lacking medical provider visit notes in both the electronic medical record (EMR) and paper charts. For four residents, there were no medical provider visit notes available in the EMR or in the paper charts at the nurse's desk, despite the residents having been admitted months prior. The process for handling provider notes involved receiving them via facsimile, review by the charge nurse, and subsequent scanning into the EMR, with the original faxed copy placed in the paper chart. However, the most recent notes had not been scanned, and in some cases, no notes were found in either record system. Staff confirmed that a nurse was present during provider visits but did not document the visit in the EMR, and the facility was in the process of changing to direct provider entry into the EMR. Additionally, the facility failed to ensure that a resident's Provider Orders for Life-Sustaining Treatment (POLST) form was properly completed, as one resident's POLST lacked a required physician signature. The unsigned POLST had been carried over from a previous facility and was not identified as incomplete during the admission or care planning process. Facility policy required that advance directives be copied and placed on the chart upon admission and reviewed periodically, but this process did not identify the missing signature.
Failure to Obtain Informed Consent Prior to Psychotropic Medication Administration
Penalty
Summary
The facility failed to obtain informed consent prior to administering psychotropic medications for two residents. For one resident, citalopram hydrobromide was ordered and administered before the resident's spouse signed the informed consent form, with the first dose given two days before consent was obtained. The same resident was later started on sertraline HCl, which was also administered before the spouse signed the consent form, with the first dose given two days prior to consent. Another resident received citalopram hydrobromide without any documented consent found in the electronic health record. This resident was also given haloperidol, with the consent form signed by the guardian two days after the medication order was received. Staff interviews revealed that the staff member responsible for obtaining consents could not explain why the consents were not completed prior to starting the medications. The facility's policy requires that residents or their representatives be informed of the risks and benefits of psychotropic medications before initiation, but this was not followed in these cases.
Failure to Limit PRN Antipsychotic Medications to 14 Days
Penalty
Summary
The facility failed to ensure that as needed (PRN) psychotropic medications, specifically antipsychotics, were limited to a 14-day duration unless a medical provider documented a rationale for continued use. For one resident with vascular dementia and delusional disorders, an order for PRN olanzapine did not specify a 14-day limit, and subsequent medication regimen reviews did not address the need to monitor or discontinue the medication after 14 days. The medication remained active beyond the allowed period without appropriate documentation or evaluation by a provider. Similarly, another resident with severe dementia and behavioral disturbances had a PRN order for quetiapine fumarate that also lacked the required 14-day limitation. The medication regimen review process did not identify or address the ongoing use of the PRN antipsychotic within the required timeframe. Staff interviews revealed a lack of understanding regarding the review process for PRN antipsychotic medications, and facility policy required PRN antipsychotic orders to be limited to 14 days, with a new evaluation needed for continued use.
Failure to Report and Investigate Suspected Financial Exploitation
Penalty
Summary
The facility failed to implement its policies and procedures for reporting a reasonable suspicion of a crime, specifically regarding the possible misappropriation of a resident's property by their conservator. A resident with encephalopathy and an appointed conservator was the subject of concern after staff noted issues with unpaid bills and suspected the conservator might be using the resident's funds for personal use. Staff discussed the issue in an interdisciplinary team (IDT) meeting, and Adult Protective Services (APS) was notified, resulting in the assignment of an APS investigator. However, there was uncertainty among staff about who was responsible for following up on the concern after the IDT meeting. Despite the facility's policy requiring immediate investigation and timely reporting of suspected exploitation to the state survey agency and other authorities, there was no evidence that the allegation was reported through the State Survey Agency reporting portal. Additionally, the facility could not provide documentation of an internal investigation into the exploitation allegation. This failure to report and investigate as required by policy and regulation constituted the deficiency.
Failure to Provide Written Transfer Notice to Resident and Representative
Penalty
Summary
The facility failed to provide written notification to a resident and/or the resident's representative regarding the reason for transfer when the resident was transferred to the hospital on two separate occasions. During interviews, a staff member confirmed that no transfer notice was completed for the resident's hospitalizations, and review of the electronic medical record did not show any documentation of such notices for the specified transfers. Additionally, when requested, the facility was unable to produce any records or documentation of the required transfer notices. The facility's own policy requires that transfer/discharge notices be provided to residents or their representatives in a language and manner they can understand.
Failure to Develop and Implement Comprehensive Activity Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan that addressed a resident's activity preferences and physical abilities. Observations showed the resident spent most of her time in bed, with limited engagement in activities. The resident reported poor vision and limited hand function, which prevented her from participating in group activities, and stated that staff had not offered her in-room activities or one-on-one visits. She expressed a desire for staff to visit her in her room, as she was unable to participate in most activities due to her physical limitations. Review of the resident's care plan revealed it did not identify her specific life roles, activities of interest, or provide for one-on-one visits, despite her expressed preferences and needs. The care plan included only general interventions such as encouraging participation in activities and supplying leisure materials as needed, without customization to her abilities or preferences. Staff interviews indicated issues with documentation and care plan customization due to changes in the facility's computer system and staffing limitations. The resident's MDS assessment confirmed she required maximal assistance for mobility and self-care, further highlighting the need for individualized activity planning.
Failure to Provide and Document Activities to Meet Resident Needs
Penalty
Summary
A deficiency was identified when a resident, who had poor vision and limited hand function, reported not participating in activities since admission. The resident stated that staff did not offer or provide one-on-one visits or in-room activities, and expressed a desire for staff to visit her, as she spent most of her time in her room. Observation confirmed the resident was alone in her room, awake, with the television off, and no activities being offered. Review of the resident's activity participation record showed no documented participation in any activities since admission. During interviews, the staff member responsible for activities acknowledged issues with documentation and stated that, due to working in two positions and limited time, she had not been documenting resident participation as required. Despite claims that the resident had participated in several activities, no documentation or records were provided to support this, and no activity assessment or evidence of one-on-one visits was available by the end of the survey.
Sanitation Deficiency in Kitchen
Penalty
Summary
The facility failed to maintain the kitchen in a sanitary and clean condition, which had the potential to affect all residents consuming food or services from the kitchen. During an observation, surveyors found white debris resembling crumbs in the corners of the kitchen floor, white, tan, and brown debris resembling crumbs and dirt underneath the shelves, and white and tan debris resembling crumbs and food particles underneath the workspace next to the stove. Additionally, a dark brown substance was observed at the edge of the floor where the mop boards meet the floor. Interviews with staff revealed that the cleaning tasks were assigned to employees on shift, with a checklist that was initially required to be completed weekly but was changed to daily due to non-compliance. Staff member G mentioned that some staff were on vacation, and there was a loss of employees after school started. A review of the facility's policy on dietary sanitization indicated that all kitchen and dining areas should be kept clean, with the food services manager responsible for scheduling regular cleaning. However, a review of the kitchen checklists for the last two months showed gaps where the checklists were not completed.
Lack of Certified Director in Food and Nutrition Services
Penalty
Summary
The facility failed to employ a certified individual to serve as the director of food and nutrition services, which could potentially affect all residents receiving food from the kitchen. Staff member C, who took over the position in November, reported having no orientation or training due to the absence of staff member G, who was involved in a car accident. Despite being in the role for six months, staff member C had not received any corporate training or oversight and was not enrolled in any dietary courses, although he planned to take the ServSafe course. The dietician was available only by phone for substitution changes and did not supervise or oversee staff member C in the kitchen. Additionally, there was no documentation of specific dietary orientation or training for staff member C.
Deficiencies in Kitchen Hygiene and Food Storage Practices
Penalty
Summary
The facility failed to maintain proper food storage and preparation standards in the kitchen, as observed during a survey. Staff members were found not wearing required hairnets and beard nets, with one staff member wearing a baseball cap instead. The kitchen had several open food items without labels or dates, including large tubs of rice, brown sugar, flour, and other ingredients. Additionally, the kitchen was found to be unclean, with dirty toasters, drink dispensers, and a chest freezer with food debris and frost buildup. The cupboards above the food prep area were also dirty, with missing laminate chunks. Further observations revealed dented cans in the dry storage room, which should have been discarded according to facility policy. Staff members admitted to not following proper procedures, with one stating that the staff often got in a hurry and neglected to label and date food items. The dietary manager's supervisor acknowledged a lack of oversight in the kitchen, contributing to the ongoing issues. The facility's policies on food labeling and hairnet usage were not being adhered to, as evidenced by the conditions found during the survey.
Expired Medications and Supplies Found in Facility
Penalty
Summary
The facility failed to remove and dispose of expired medications and medical supplies in both the medication room and the treatment room, as observed during a survey. In the medication room, expired items included Coaguchek XS PT test strips, glucose control solution set, sodium chloride injection solution, a red top blood collection tube, and Monoject hypodermic needles. In the treatment room, expired items included various types of catheters. During interviews, staff members acknowledged the oversight, with one staff member admitting to missing the expired items during checks. Additionally, it was revealed that the facility lacked a specific policy addressing the management of expired medications and supplies.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to provide palatable food at an appetizing temperature for three residents. Observations and interviews revealed that the food served was consistently cold. Resident #200 expressed dissatisfaction with the food quality, stating it was always cold. Temperature checks conducted by staff member C on various dates showed that food items such as eggs, hashbrowns, and cream of wheat were served at temperatures significantly below the required 135 degrees Fahrenheit. Additionally, the steam table used to keep food warm was found unplugged and not turned on, contributing to the issue. Further observations indicated that the steam table was not functioning properly, and a new steam table was available but not assembled. Resident #38 also complained about cold food, opting to eat only her salad. Staff members acknowledged the problem, noting that food was served on cold plates with unheated plate warmers, exacerbating the issue. The facility's policy on meal assistance, which mandates that hot foods be held at 135 degrees or above until served, was not adhered to, leading to the deficiency.
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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