Beartooth Rehabilitation And Nursing Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Columbus, Montana.
- Location
- 350 W Pike Ave, Columbus, Montana 59019
- CMS Provider Number
- 275159
- Inspections on file
- 8
- Latest survey
- February 10, 2026
- Citations (last 12 mo.)
- 51 (2 serious)
Citation history
Health deficiencies cited at Beartooth Rehabilitation And Nursing Llc during CMS and state inspections, most recent first.
Surveyors found that the facility failed to enforce its smoking policy and accident-prevention measures for multiple smokers, including a resident on O2 who used an open-flame lighter near oxygen equipment and smoked in an outdoor area while wearing a nasal cannula and having a portable O2 tank attached to a wheelchair. The outdoor smoking area lacked required signage and staff supervision, and residents reported that smokers went outside unsupervised. Another resident with a history of marijuana-related incidents kept cigarettes and a lighter accessible in her room despite a care plan and smoking safety screen requiring the lighter to be stored at the nurse’s station. Additional smokers and vape users were not consistently identified on the smoking list or addressed in care plans, and one resident was observed rolling cigarettes in his room with multiple lighters present. These conditions led to an Immediate Jeopardy citation under F689 for accidents and hazards.
The facility failed to protect multiple residents from abuse and neglect. A cognitively impaired resident with known boundary and sexual behavior issues repeatedly engaged in inappropriate physical contact with female residents, yet his care plan lacked specific interventions or protections before and after these events, and the facility did not substantiate abuse despite documented behaviors. A staff member verbally abused a resident by directing profane, demeaning language toward the resident, and interviews revealed a pattern of rudeness that made residents feel small. Another resident with a known history of exploitation and leaving prior facilities eloped five times over a short period, each time without staff awareness and once reaching a busy area near an interstate, showing that effective measures to prevent further elopements were not implemented.
The facility failed to submit required investigative findings to the State Survey Agency within five working days for multiple reportable events, including verbal mistreatment in a dining room, allegations of inappropriate touching between residents, and several elopement incidents. Staff responsible for reporting acknowledged that final investigation reports were submitted late, and one staff member cited being reassigned to kitchen duties as a reason for a delay. These actions did not follow facility policies that require the administrator or designee to report investigation results to appropriate agencies within the specified timeframe.
A resident repeatedly eloped from the facility without staff knowledge, and the facility failed to conduct thorough investigations into these incidents. Investigation files lacked staff and resident interviews, did not identify root causes, and in one case contained no investigative information beyond chart copies. Staff reported the resident had a history of homelessness, was possibly in a witness protection program, and was allowed to smoke outside unattended due to limited manpower. A staff member who had ideas about how and why the resident eloped was never interviewed, and the staff member responsible for the investigation admitted that a comprehensive review, including staff interviews, was not completed. The resident was consistently found by community members rather than facility staff, and documentation of staff re-education on elopement prevention was incomplete and undated.
A cognitively impaired, nonverbal resident with a history of wandering experienced an unwitnessed fall resulting in a major injury. Staff failed to perform a thorough assessment, did not document the incident properly, and delayed notifying the DON and transferring the resident to the hospital. The resident required surgery for a hip fracture and lost independent ambulation. Facility policies for fall prevention and post-fall care were not followed.
A resident with severe cognitive impairment experienced an unwitnessed fall resulting in significant injury. Staff failed to thoroughly assess the resident, did not use a mechanical lift for transfers, and left the resident in pain and soiled clothing. The incident was not properly documented or reported to the State Survey Agency, and communication among staff was incomplete and inaccurate.
Staff failed to conduct a thorough assessment, pain evaluation, or proper transfer for a resident after an unwitnessed fall with injury. The resident, who was non-verbal and cognitively impaired, was moved without a mechanical lift and later showed increased pain. No pain or fall assessment was documented, and incident documentation was delayed by over four months, contrary to facility policy and professional standards.
The facility did not maintain documentation or demonstrate evidence of an ongoing QAPI program, failed to systematically identify and address adverse events such as falls and infections, and did not submit or investigate reportable incidents as required. Staff interviews and record reviews confirmed the absence of regular care conferences, incomplete documentation, and lack of performance improvement activities.
The QAPI committee did not meet regulatory requirements for membership and participation, as only a few staff members attended meetings and there was no evidence of the Medical Director or designee's involvement. This failure to assemble the required interdisciplinary team and hold proper quarterly meetings had the potential to impact all residents.
The facility did not consistently provide required written notifications of resident transfers and discharges to the local Ombudsman, as mandated by policy. Several residents were transferred to hospitals or discharged, but the responsible staff member failed to send or retain copies of the notifications, and the Ombudsman reported not receiving them for an extended period.
A resident who was not a reliable reporter experienced an unwitnessed fall resulting in a hip fracture that required surgery and hospitalization. Despite clear evidence of serious injury and facility policy requiring immediate reporting, staff did not report the incident to the State Survey Agency or document an investigation. Interviews revealed that the Administrator and other staff were unaware of or did not follow required reporting procedures, and no facility-reported incidents were submitted during the relevant period.
A resident experienced an unwitnessed fall resulting in a fractured hip that required surgery and hospitalization. Facility staff did not initiate or document an abuse or neglect investigation, failed to report the incident to the State Survey Agency, and did not follow internal policies for incident reporting and investigation. Staff interviews revealed a lack of understanding and documentation regarding reporting requirements, and no investigation or interviews were conducted following the event.
A resident who sustained a hip fracture and became non-ambulatory after a fall did not receive a Significant Change MDS assessment as required. Instead, staff completed a Quarterly MDS, despite the resident's increased dependence on staff for mobility and daily care. The responsible staff member acknowledged the oversight and stated that only the RAI manual was used for MDS policy guidance.
A Quarterly MDS assessment for a resident was not submitted within the required timeframe, with the responsible staff member citing workload and additional shift coverage as reasons for the delay. The assessment was completed but submitted 11 days late, contrary to facility policy requiring timely submission of MDS data.
A resident receiving daily insulin injections and oral hypoglycemic medication for type 2 diabetes was not accurately coded for these medications on the MDS assessment. Despite clear documentation in the MAR and physician orders, the MDS sections for injections and hypoglycemic use were marked incorrectly, and the staff member responsible could not explain the omission.
A resident receiving telehealth mental health services for PTSD did not have these services reflected in their comprehensive care plan. Staff confirmed that care plans should address mental health concerns and interventions, but the plan only included medication management and monitoring, omitting the behavioral health services being provided.
The facility did not make grievance forms or the grievance official's contact information readily available, nor did it provide a clear option for residents to file grievances anonymously. Two residents were unaware of how to file a grievance or where to find the necessary forms, and staff confirmed that required postings and receptacle labels had not been maintained.
The facility did not make the most recent certification survey results readily available in common areas after renovations, as confirmed by staff and a resident who was unaware of the survey binder's location.
A resident's room was found to be persistently unclean and hazardous, with an exposed air conditioning unit, soiled bathroom, littered floor, and a full waste bin. Despite facility policies requiring daily housekeeping, the room remained in this condition over several days, and both the resident and family expressed dissatisfaction with the cleanliness and the need to request cleaning services.
Surveyors found that the facility did not develop or implement comprehensive, individualized care plans for four residents with complex needs, including those with communication deficits, immobility, pressure ulcer risk, and diabetes. Care plans lacked measurable, person-centered interventions and did not address key areas such as communication strategies, pressure ulcer prevention, or diabetes management. Staff interviews indicated a reliance on shift reports rather than care plans for guiding resident care.
Staff failed to follow infection prevention and control protocols, including not wearing required PPE during high-contact care, not implementing Enhanced Barrier Precautions, and not maintaining proper hygiene during medication administration. Additionally, laundry staff lacked knowledge of infection control measures and did not use protective gowns when handling soiled clothing.
Two residents experienced unsanitary bathroom conditions, with fecal material observed on toilets over several days and no evidence of cleaning, despite staff claims of daily cleaning and the absence of cleaning logs or policies.
Two residents experienced significant changes in their medical conditions—one with a new suprapubic catheter and another with a new diabetes diagnosis—but their care plans were not updated to reflect these changes. Staff relied on verbal and written shift reports rather than consistently revising care plans, despite facility policy requiring updates after hospitalizations or significant changes.
A staff member crushed and administered a delayed-release medication, Depakote, which is not recommended to be crushed, to a resident in order to facilitate swallowing. The staff member acknowledged this practice, despite facility pharmacy guidance indicating that Depakote should not be crushed, and a physician order allowing crushing only when not contraindicated.
A resident with ALS who was dependent on staff for ADLs was not provided with frequent turning or repositioning, resulting in new skin redness to the coccyx and perineum. The care plan and EHR did not address or document frequent turning, and observations showed the resident remained in the same position for extended periods, requiring her to request assistance via the call button.
A resident with ALS and respiratory concerns did not have physician orders for BiPAP parameters documented in the medical record. Staff were unclear about oxygen delivery settings and the meaning of physician instructions, and the resident's care plan did not address her BiPAP needs or related anxiety.
A resident received PRN diazepam for anxiety and mood on 23 occasions each month over a two-month period, with the order lacking a required 14-day stop date. The medication order remained active without documented evaluation or re-evaluation of the resident's need, and staff were unaware of the missing stop date until it was brought to their attention.
Failure to Enforce Smoking Safety and Oxygen Precautions
Penalty
Summary
The deficiency involves the facility’s failure to implement and operationalize its smoking policy and accident-prevention practices for multiple residents who smoked, including those using oxygen and those with a history of unsafe smoking behaviors. Surveyors found that the facility did not maintain an accurate list of residents who smoked, omitting one resident who had a documented smoking safety screen. The facility also failed to identify and address individualized smoking safety risk factors in care plans for several residents, and did not ensure that smoking materials, such as lighters, were secured as required by assessments and care plans. One resident using oxygen was observed engaging in unsafe practices on multiple occasions. In her room, she used a lighter with an open flame to heat craft materials while an oxygen concentrator was present, with no oxygen hazard or no-smoking signage on the door. She was later observed in the designated outdoor smoking area wearing a nasal cannula with a portable oxygen tank attached to her wheelchair while smoking a lit cigarette, and another resident sat nearby also smoking. The resident stated she turned off the oxygen and moved the cannula, but the oxygen tank gauge still showed pressure. Staff interviews revealed that some staff believed it was unsafe for her to have lighters in her room or to go outside with oxygen, yet her smoking safety screen incorrectly documented that she did not use supplemental oxygen and deemed her safe to smoke without supervision. Another resident, identified as a smoker, kept cigarettes and a lighter accessible in her bedside dresser drawer despite a history of marijuana-related concerns documented in progress notes, including reports of her allegedly smoking marijuana on the premises and staff and law enforcement involvement. Her care plan initially identified her as at risk for injury related to smoking and allowed independent smoking, with an intervention later added requiring her lighter to be stored at the nurse’s station. However, during observation, the lighter remained in her room and accessible, contrary to the care plan and smoking safety screen that specified the lighter should be locked at the nurse’s station. Additional residents who smoked or used vapes were not consistently assessed or care planned for smoking or vaping, including one resident listed as a smoker whose record and care plan did not address smoking or vape use, and another resident who reported being independent with smoking and had a smoking safety screen for an electronic cigarette, but whose vape had been found on a heater and removed by staff. A further resident who smoked was not included on the facility’s smoking list despite having a smoking safety screen completed shortly after admission. This resident was observed rolling cigarettes in his room with several lighters and bags of tobacco on his dresser and stated that smoking times were flexible and that smokers outside were not supervised by staff. He also reported that another resident had to wear a smoking apron because she had burned her clothes and believed the apron was a punishment. The facility’s written policies required a designated smoking area with posted signage, prohibition of oxygen use in the smoking area, and maintenance of smoking materials by nursing staff for residents requiring supervision, as well as staff involvement in identifying environmental hazards. Observations showed the outdoor smoking area lacked visible designated smoking and no-oxygen signage, residents smoked there without staff supervision, and oxygen equipment was present in the area, all contrary to the facility’s policies. The surveyors determined that these failures contributed to an Immediate Jeopardy situation related to accidents and hazards, specifically involving the resident using oxygen while smoking. The Immediate Jeopardy was cited at F689 – Accidents and Hazards at a severity and scope level of J before later being reduced in severity after the immediacy was removed.
Failure to Prevent Resident‑to‑Resident Sexual Contact, Verbal Abuse, and Repeated Elopements
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from abuse and neglect, including inappropriate physical contact between residents, verbal abuse by staff, and repeated elopements. One resident with severe cognitive impairment and a history of boundary issues was documented as inappropriately touching another resident’s bottom and seeking out female residents to touch or kiss, as well as groping himself while looking into female residents’ rooms. Despite this, his care plan did not include documentation or interventions specific to sexual behaviors or lack of physical boundaries, either before or after the incident. A subsequent incident involving the same resident bumping another female resident’s thigh occurred after staff had already noted increased sexual behaviors and disruptive conduct, yet the care plan still lacked protective measures or behavior-specific interventions. Facility investigation notes indicated that both cognitively impaired residents involved could not recall the incidents, and the events were deemed “unable to substantiate,” even as staff acknowledged the resident’s sexual behaviors and instructed him to keep his hands to himself. The deficiency also includes an incident of verbal abuse toward a resident by a staff member. During shift change, a staff member directed profane and demeaning language at a resident, telling the resident to “shut the f k up.” The facility’s investigative report substantiated that this statement was made as alleged, and interviews identified additional reports that the same staff member was rude and made residents feel small. The facility’s own findings characterized the language used toward the resident as verbal abuse, confirming that the resident was not kept free from abusive treatment. Additionally, the facility failed to prevent neglect related to repeated elopements by another resident. Over a 43‑day period, this resident left the facility five times without staff awareness, and each time was found in the community rather than on facility grounds, including once approximately one mile away at a busy stop near an interstate. The resident had been admitted from a sister facility and had a known history of leaving to go to a park where she exchanged sex for drugs and had been exploited for sex and drugs. Despite this history and the repeated elopements, the resident was able to leave the facility multiple times without detection, demonstrating that effective plans and protections to prevent further elopements were not in place.
Failure to Timely Submit Investigation Results for Abuse, Neglect, and Elopement Incidents
Penalty
Summary
The deficiency involves the facility’s failure to submit investigative findings for multiple reportable abuse and neglect incidents to the State Survey Agency within the required five working days. For one resident, an incident report submitted on 10/2/25 documented mistreatment in the dining room through verbal comments from other residents, but the facility did not submit the investigative findings until 10/10/25, one day past the deadline. For another resident, an incident involving reported inappropriate touching by another resident was submitted on 1/3/26, but the investigative findings were not reported until 1/11/26, two days late. A third resident reported inappropriate and unwanted touching by another resident in an incident submitted on 1/25/26, and the facility did not submit the investigative findings until 1/31/26, one day after the deadline. The facility also failed to timely submit final investigation reports for multiple elopement incidents involving another resident. An allegation of neglect related to an elopement on 11/1/25 at 10:20 a.m. was reported on 11/1/25, but the final investigation was not submitted until 11/10/25, three days late. A second elopement for the same resident on 11/1/25 at 5:40 p.m. and a third elopement on 12/3/25 were similarly reported, with final investigations submitted on 11/10/25 and 12/11/25, respectively, each beyond the five-day requirement. Interviews with staff responsible for submitting these reports confirmed that the final investigations for these incidents were submitted late, with one staff member attributing a delay in one case to being reassigned to work in the kitchen. Facility policies on abuse, neglect, and exploitation, and on compliance with reporting allegations, require the administrator or designee to report the results of investigations to appropriate agencies within five working days of the incident.
Failure to Thoroughly Investigate and Analyze Repeated Resident Elopements
Penalty
Summary
The facility failed to ensure a thorough investigation of multiple elopements involving resident #46. Facility-reported incidents documented that the resident left the premises without staff knowledge on several occasions over a span of weeks. The investigative files for these events lacked staff and resident interviews, did not identify root causes, and in one case contained no investigative information beyond copies of portions of the chart. The final report for the first elopement stated staff would be re-educated on elopement prevention procedures, but there was no documentation that this education occurred on or near the date of the incident, and the only education roster provided lacked a date, content description, and the name of the presenter. Staff interviews further showed that the investigations were not comprehensive. One staff member reported that the resident had a history of living in a homeless shelter and was potentially in a witness protection program, and that the resident was allowed to be outside smoking unattended because the facility did not have the manpower to supervise smokers. This staff member also stated that the resident’s activity care plan had been changed but could not recall what was needed to prevent further elopements. Another staff member stated she had never been interviewed about the elopements despite having ideas about how and why they occurred and how to prevent them. The staff member responsible for the investigation admitted she did not complete staff interviews and that a comprehensive review was not done, even though the facility later learned the resident had gone under a fence during one elopement rather than over it as initially believed. Across five additional elopements, the resident was identified as missing by community members rather than facility staff, and the investigation files remained incomplete and without timelines or precipitating factors.
Failure to Supervise and Assess Cognitively Impaired Resident After Fall
Penalty
Summary
The facility failed to provide adequate supervision and monitoring for a cognitively impaired resident with a history of wandering, resulting in an unwitnessed fall that caused a major injury. The resident, who had Alzheimer's disease and was nonverbal, was found on the floor in the dining room by staff after the fall. Staff manually lifted the resident from the floor to a wheelchair and then to bed, despite the resident showing signs of pain and having a visible hematoma on her head. The nurse on duty did not perform a thorough assessment of the resident's lower extremities and did not complete a pain assessment or document the incident properly in the medical record. Communication among staff was incomplete and inconsistent. The night shift nurse did not immediately communicate all symptoms, including the resident's hip pain, to the DON, which delayed the decision to send the resident to the hospital. The resident remained in the facility overnight, and only after the day shift nurse assessed her condition and noted significant pain and a deformity of the hip was EMS called and the resident transferred to the hospital. The delay in transfer resulted in the resident requiring hospitalization and surgery for a hip fracture, and she lost her ability to ambulate independently. The facility's policies and procedures for fall prevention, post-fall assessment, and notification of changes were not followed. Required documentation, such as a complete neurological assessment and pain evaluation, was missing or incomplete. The care plan for the resident, which identified her as a high fall risk due to wandering and cognitive impairment, was not adequately implemented to prevent the accident or ensure timely and appropriate response after the fall.
Failure to Recognize, Assess, and Report Resident Neglect After Major Fall
Penalty
Summary
The facility failed to recognize and protect a resident's right to be free from neglect following a major injury sustained from an unwitnessed fall. The resident involved had severe cognitive impairment and was non-verbal, making her an unreliable reporter of the event. After the fall, staff did not thoroughly assess the resident, particularly neglecting to assess her lower extremities despite her showing signs of pain. The staff manually lifted and transferred the resident without using a mechanical lift, contrary to facility policy, and failed to document the incident accurately in the medical record. The resident was left in pain and in soiled clothing until the following shift, when a more thorough assessment revealed a significant injury requiring hospitalization and surgery. Multiple staff interviews revealed confusion and lack of adherence to facility protocols regarding post-fall assessment, documentation, and reporting. The nurse on duty did not complete a full assessment or pain evaluation, and failed to document the incident properly after striking out the initial note. Communication among staff was incomplete, with inaccurate information relayed to the resident's family and other staff members. The decision not to send the resident to the hospital was made without a thorough assessment, and staff expressed discomfort with this decision but did not escalate the issue appropriately. The facility also neglected to report the unwitnessed fall with significant injury to the State Survey Agency, as required by both facility policy and federal regulations. The administrator, who also served as the Abuse Prevention Coordinator and Grievance Officer, was unaware of the need to report such incidents and had not submitted any facility-reported incidents in the previous six months. Education on post-fall assessment and reporting was not provided to staff until several months after the incident, further indicating a lack of timely response to the deficiency.
Failure to Perform Post-Fall Assessment and Documentation
Penalty
Summary
Facility staff failed to perform a thorough head-to-toe assessment, pain assessment, or appropriate transfer for a resident following an unwitnessed fall with injury. After being notified of the fall, staff members found the resident lying on the floor in the dining room. The staff picked up the resident and placed her in a wheelchair without using a mechanical lift, despite the resident being non-verbal, cognitively impaired, and later showing signs of pain. The staff then transferred the resident to bed, where she exhibited further signs of pain when her clothing was removed. Staff communicated concerns to each other, but the nurse on duty did not complete a full assessment of the resident's lower extremities, did not document a pain assessment, and did not properly document the incident in the medical record at the time of the event. Review of the resident's records showed no documentation of a pain assessment or fall assessment following the incident, and a late entry note was made 140 days after the fall. Facility policies required comprehensive assessments and care in accordance with professional standards, including assessment after any fall. The failure to follow these protocols resulted in an increase in the resident's signs and symptoms of pain due to a hip fracture sustained during the fall.
Failure to Implement and Document QAPI Program and Event Reporting
Penalty
Summary
The facility failed to maintain documentation and demonstrate evidence of an ongoing QAPI program that meets regulatory requirements. Staff interviews revealed that there was no QAPI plan in place at the time of the survey, and staff were still in the process of implementing one. Data collection was reportedly occurring through risk management, chart review, and infection prevention binders, but there was a lack of systematic identification, reporting, investigation, analysis, and prevention of adverse events. Staff also indicated that regular care conferences with residents or their representatives were not being held, which limited the gathering and presentation of feedback to the QAPI committee for identifying quality-of-care concerns. Review of facility documents showed that while some QAPI meetings were held and incidents such as falls and urinary tract infections were noted, there was no documentation of tracking, root cause analysis, or performance improvement projects (PIPs) being initiated when indicated. Additionally, the facility had not submitted any facility-reported incidents to the State Survey Agency and could not provide completed investigations for any reportable events. The administrator, who was also serving in multiple roles, acknowledged not documenting incidents or investigations and was unaware of issues requiring reporting. The QAPI program and performance plans did not show active identification or correction of concerns related to event reporting or follow-up.
QAPI Committee Lacked Required Membership and Participation
Penalty
Summary
The facility failed to ensure that its Quality Assessment and Assurance (QAA) group had the required members and met at least quarterly, as mandated by policy. Interviews with staff revealed that only a limited number of staff members, specifically staff member A, staff member B, and occasionally staff member G, attended the QAPI meetings. Staff member G, who was only onsite once a month, did not attend meetings in person and was only informed of the meeting outcomes after the fact via phone call. There was no documentation to confirm that staff member C attended any meetings by phone, and staff member A acknowledged that additional required members had not been invited to participate in the QAPI meetings. Review of QAPI meeting minutes and attendance sheets confirmed that the required interdisciplinary team composition was not met, with only a few staff members present and no evidence of the Medical Director or designee's participation. The facility's own QAPI policy specified that the committee must include the Director of Nursing Services, the Medical Director or designee, and at least three other staff members, including the administrator. The lack of appropriate committee membership and participation had the potential to affect all residents receiving care in the facility.
Failure to Notify Ombudsman of Resident Transfers and Discharges
Penalty
Summary
The facility failed to provide routine written notifications of resident transfers and discharges, including required information to the local Ombudsman, for four of twelve sampled residents. Specifically, documentation showed that several residents were transferred to hospitals or discharged due to death, but the required notices were not sent to the Ombudsman as mandated. Interviews revealed that the staff member responsible for sending these notifications did not consistently provide them, either by email or mail, and did not maintain copies of the notices. The Social Services Director or designee was expected to send these notifications, but this process was not followed for several months. Facility policy required that notices of transfer or discharge, including emergency transfers, be sent to the Ombudsman as soon as practicable and that evidence of such notifications be maintained. However, the Ombudsman reported not receiving these notices for months, and the staff member acknowledged not having sent or retained copies of the required documentation. A retrospective list of transfers and discharges was eventually provided, but it did not demonstrate timely or routine notification as required by policy.
Failure to Report and Investigate Serious Fall Resulting in Hip Fracture
Penalty
Summary
The facility failed to implement and uphold its policies and procedures for reporting an unwitnessed fall involving a resident who was not a reliable reporter. The resident sustained a hip fracture, required surgery, and was hospitalized as a result of the fall. Despite the severity of the injury and the resident's unreliable reporting, the incident was not reported to the State Survey Agency as required. Documentation showed that staff were aware of the fall and the resulting injuries, but the event was not identified as neglect of care or reported as a facility-reported incident. Interviews with staff revealed that the Administrator, who also served as the Social Services Designee, Business Office Manager, Grievance Officer, and Abuse Prevention Coordinator, was unaware of quality-of-care concerns that would require reporting and investigating as facility-reported incidents. The Administrator admitted to not documenting incidents consistently and stated that no facility-reported incidents had been submitted to the State Survey Agency within the last six months, including the event involving the resident's fall and hip fracture. Another staff member confirmed that no reportable incidents had been submitted and described consulting with another staff member, who advised against reporting the event. Review of the resident's nursing progress notes indicated that after the fall, the resident exhibited significant injuries, including a large hematoma, a skin tear, and severe pain in the hip area. The initial response included canceling EMT transport and observing the resident overnight, with a portable X-ray ordered for the following morning. The next day, the resident was found in pain with a suspected broken hip, and EMS was called. The facility's policy required immediate reporting of alleged violations involving serious bodily injury, but no such report was made, and no investigation documentation was provided.
Failure to Investigate and Report Unwitnessed Fall Resulting in Major Injury
Penalty
Summary
The facility failed to initiate an abuse or neglect investigation after a resident experienced an unwitnessed fall that resulted in a major injury, specifically a fractured hip requiring surgery and hospitalization. Despite the severity of the incident, there was no documentation of a facility-reported incident, no investigation was completed, and the event was not reported to the State Survey Agency. Staff interviews revealed a lack of awareness and understanding of reporting requirements, with staff relying on corporate direction to determine whether to report and investigate such incidents. The facility also lacked prepared reports or tracking systems for monitoring incidents over time. Review of the resident's medical records indicated that the resident was found in pain with a broken hip and urine-soaked clothing, and was subsequently hospitalized and treated for additional complications, including blood clots. The facility's own policy required written procedures for reporting and investigating abuse or neglect, including analyzing occurrences and reporting results to government agencies. However, the facility did not follow these procedures, as no investigation or interviews were conducted, and no documentation was submitted for review. Staff admitted to not documenting or investigating unless instructed by corporate, and there was no evidence of compliance with the facility's abuse and neglect policy.
Failure to Complete Significant Change MDS After Resident Decline
Penalty
Summary
The facility failed to complete a Significant Change Minimum Data Set (MDS) assessment for a resident who experienced a notable decline in condition following a fall and subsequent hip fracture. After the resident fell and sustained a hip fracture, she underwent surgery and returned from the hospital in a non-ambulatory state. Despite this significant change in her mobility and care needs, the staff member responsible for MDS assessments completed a Quarterly MDS instead of a Significant Change MDS, as required by the Resident Assessment Instrument (RAI) guidelines. The staff member acknowledged during an interview that a Significant Change MDS should have been completed and that she would refer to the RAI guidelines in the future to determine the appropriate assessment. Record review showed that prior to the fall, the resident was independent with ambulation and required only supervision or substantial assistance for other activities of daily living. After the incident, the resident became dependent on staff for transferring, toileting, bathing, dressing, and personal hygiene, and was coded for wheelchair use. The facility's policy for MDS assessments is based solely on the RAI manual, with no additional internal policies in place. The failure to complete the required Significant Change MDS assessment meant that the resident's substantial decline in function was not formally identified through the MDS process.
Late Submission of Quarterly MDS Assessment
Penalty
Summary
The facility failed to submit a Quarterly Minimum Data Set (MDS) assessment within the required timeframe for one resident. The assessment, with an Assessment Reference Date (ARD) of 7/11/2025, was completed on 7/25/2025 but was not submitted and accepted until 8/19/2025, which was 11 days past the required submission date. During an interview, the staff member responsible for completing the MDS assessments acknowledged that some assessments were late due to being overburdened with responsibilities, including covering additional shifts on the floor. Review of the facility's policy confirmed the requirement to utilize the current version of the RAI (MDS 3.0) and follow the instructions in the RAI Manual.
Failure to Accurately Code Insulin and Hypoglycemic Medication on MDS Assessment
Penalty
Summary
The facility failed to accurately code medications on the Minimum Data Set (MDS) assessment for one resident. Specifically, the resident's Quarterly MDS did not reflect the administration of insulin or other hypoglycemic medications during the 7-day look-back period, despite documentation in the Medication Administration Record and physician orders indicating that the resident received daily insulin injections and oral metformin for type 2 diabetes mellitus. The relevant MDS sections (N0300, N0350, and N0410) were either marked as zero or 'No' for injections and hypoglycemic medication use, which was inconsistent with the resident's actual medication regimen. Interview with the staff member responsible for completing the MDS assessments revealed uncertainty regarding why insulin or hypoglycemic medications were not marked for this resident. The facility's policy required the use of the current RAI (MDS 3.0) and accurate inclusion of medications as per the RAI Manual, but this was not followed in this instance. The deficiency was identified through review of the resident's records and staff interview.
Care Plan Lacked Inclusion of Behavioral Health Services
Penalty
Summary
The facility failed to revise a comprehensive care plan to include behavioral health services for one resident who was receiving mental health care via telehealth. Staff interviews confirmed that care plans should address mental health concerns, including both pharmacological and non-pharmacological interventions, as well as any triggers and pertinent behavioral health information. Record review showed that the resident's care plan, which identified a mood problem related to PTSD, included medication administration and monitoring but did not reflect the ongoing telehealth services provided by a mental health professional.
Failure to Provide Accessible Grievance Process and Information
Penalty
Summary
The facility failed to develop and implement a grievance policy that included the name and contact information for the grievance official, did not provide residents with readily available grievance forms, and did not ensure residents had the option to file grievances anonymously. During a walkthrough of the facility's common areas, surveyors observed that no grievance forms were accessible to residents, there was no posting of the grievance official's contact information, and no secure receptacle was identified for anonymous grievance submission. Staff confirmed that grievance forms were kept in an office rather than in a public area, and that previous postings and receptacle labels had been removed by a resident and not replaced. Interviews with two residents revealed that they were unaware of how to file a grievance, where to find grievance forms, or the existence of a secure receptacle for anonymous submissions. One resident reported that concerns were typically relayed to staff through direct conversation or via a family member, rather than through a formal grievance process. Review of the facility's grievance form and policy showed that required information, such as the grievance official's contact details, was missing from the form, and the policy, while outlining requirements, was not being followed in practice.
Failure to Post Certification Survey Results in Accessible Area
Penalty
Summary
The facility failed to post the results of the most recent certification survey in an area that was easily accessible to residents, family members, and residents' legal representatives. During an observation, no binder containing the survey results was found in the common areas. Staff confirmed that the survey information had been removed during recent renovations and had not been reposted afterward. Additionally, a resident interviewed was not aware of the location of the binder containing the most recent survey results.
Failure to Maintain Clean and Hazard-Free Resident Room
Penalty
Summary
A deficiency was identified when a resident's room was found to be unclean and hazardous over multiple days. Observations revealed that the air conditioning unit in the room had its front panel removed, exposing internal components and an electrical wire, with a heavy accumulation of dust and grime indicating a lack of maintenance. The resident's bathroom toilet was soiled with urine and feces both inside and outside the bowl, and the floor was littered with tissue paper, medication cups, a plastic cup, scraps of paper, and dried brown spots from a spill. The waste bin was full, and the room had not been cleaned for an extended period, as confirmed by the resident, who stated she had to request housekeeping services and was dissatisfied with the cleanliness. Family members also expressed concern about the facility's cleanliness, describing it as atrocious and stating it was not appropriate to have to ask staff to clean the room. Staff interviews indicated that rooms were supposed to be cleaned daily, including sweeping, mopping, and cleaning of bathrooms and surfaces. However, repeated observations over consecutive days showed the resident's room remained in the same unclean condition, with no evidence of housekeeping intervention. Facility policy and the standard admission agreement both required daily housekeeping and routine cleaning to maintain a safe and sanitary environment, but these standards were not met in this instance.
Failure to Develop and Implement Comprehensive, Resident-Centered Care Plans
Penalty
Summary
The facility failed to implement comprehensive, resident-centered care plans that addressed the physical and psychosocial needs of four residents. For a resident with a traumatic brain injury and communication difficulties, the care plan did not include a focus area or interventions for communication deficits, nor did it provide guidance for staff on how to communicate effectively with the resident. Another resident with multiple sclerosis and limited mobility had a care plan that lacked measurable, person-centered interventions for the prevention and management of pressure ulcers and dehydration, despite being at risk due to immobility and medication side effects. A third resident, who was paraplegic and had a history of pressure ulcers, did not have a care plan that included specific, measurable interventions for pressure ulcer prevention, and staff failed to follow up on the resident's requests for necessary equipment to assist with repositioning. Additionally, a resident with Type 2 diabetes and unspecified complications did not have a care plan addressing diabetes management, monitoring, or related complications. Staff interviews revealed reliance on shift reports rather than care plans for resident care information, and the staff member responsible for care plans did not ensure comprehensive, individualized plans were in place as required by facility policy.
Failure to Implement and Adhere to Infection Prevention and Control Practices
Penalty
Summary
Staff failed to adhere to proper infection prevention and control practices in several areas of the facility. In the laundry department, a staff member was unable to explain whether the washing machine killed pathogens by heat or chemicals and did not wear a protective gown when handling residents' clothing, contrary to infection control principles outlined in facility policy. The Housekeeping/Laundry Competency Checklist required review of correct infection control principles, but staff demonstrated a lack of knowledge and compliance. Enhanced Barrier Precautions (EBP) were not consistently implemented or followed for residents requiring such measures. Staff were observed performing high-contact care activities, such as PEG tube flushes and catheter care, without wearing required gowns or gloves. There was also a lack of EBP signage and supplies in resident rooms where these precautions were indicated. Interviews revealed that some staff were unfamiliar with EBP protocols and that training on these precautions was only being conducted after deficiencies were identified. During medication administration, a nurse placed medications on an uncleaned dresser surface without a protective barrier and failed to perform hand hygiene before donning gloves to administer an injection. Facility policy required staff to follow infection control procedures, including handwashing and use of barriers, during medication administration. These lapses in infection control practices were observed directly and confirmed through staff interviews and review of facility policies.
Failure to Maintain Clean and Sanitary Resident Bathrooms
Penalty
Summary
The facility failed to maintain a clean and sanitary environment for two residents, as evidenced by repeated observations of soiled toilets in their rooms over multiple days. For one resident, brown specks, appearing to be feces, were observed on the front part of the toilet bowl on three consecutive days, with no indication that the toilet had been cleaned during that period. The resident's family member also reported that the toilet was sometimes dirty during visits. Staff interviews confirmed that cleaning was supposed to occur daily, but there was no documentation or cleaning log to verify this. Another resident reported that the facility did not clean the bathrooms enough, and surveyors observed smeared fecal material on the toilet seat and inside the toilet bowl over a span of three days, with no change in the condition of the toilet. Despite being notified by the surveyor, staff did not address the issue, and the resident confirmed that the bathroom had not been cleaned. Staff interviews revealed that there was no specific cleaning log or policy in place, and the facility was unable to provide housekeeping cleaning logs or policies when requested.
Failure to Update Care Plans After Significant Changes in Resident Condition
Penalty
Summary
The facility failed to update care plans for two residents following significant changes in their medical conditions. One resident, who previously had an indwelling catheter, was transferred to the hospital for a suprapubic catheter insertion and returned the same day. Although physician orders were updated to reflect the new catheter and required dressing changes, the resident's care plan was not revised to include this information. Staff interviews revealed that the responsibility for updating care plans fell to a single staff member, who acknowledged that not all care plans had been updated following hospital discharges. Another resident returned from the hospital with a new diagnosis of diabetes, but the care plan did not reflect this change, lacking any focus area, goals, interventions, or monitoring related to diabetes management. Staff interviews indicated that information about changes in resident care was primarily communicated verbally or through shift reports, rather than through updated care plans. The facility's policy required the interdisciplinary team to review and update care plans after significant changes or hospital readmissions, but this was not consistently followed.
Delayed-Release Medication Inappropriately Crushed During Administration
Penalty
Summary
Staff member F failed to adhere to professional standards of practice by crushing a delayed-release medication, Depakote (Divalproex Sodium), which is not recommended to be crushed, for one resident during medication administration. During observation, staff member F removed metformin and Depakote from their packaging and crushed both medications before administering them in pudding to the resident. Staff member F acknowledged that Depakote was routinely crushed to aid the resident in swallowing, despite stating she typically did not crush delayed or extended-release medications. Facility pharmacy documentation specifically listed Depakote as a medication that should not be crushed, as this can alter the drug's intended mechanism. The resident's physician order allowed for medications to be crushed unless otherwise specified or contraindicated, but did not override the contraindication for Depakote.
Failure to Provide Frequent Repositioning for Dependent Resident with ALS
Penalty
Summary
A deficiency was identified when a resident with Amyotrophic Lateral Sclerosis (ALS), who was dependent on staff for activities of daily living, was not provided with adequate assistance for frequent turning and repositioning to prevent skin breakdown. The resident's electronic health record (EHR) and baseline care plan indicated a need for substantial assistance by staff for turning and repositioning, as well as total or substantial assistance for other ADLs. Despite this, there was no documentation of frequent turning or repositioning in the EHR, and no physician's order or care plan intervention specifically addressing the need for frequent turning to prevent skin breakdown. Observations and interviews revealed that the resident developed new redness to the coccyx and perineum, and was consistently found in the same position on a pillow in her recliner over multiple days. The resident reported that staff did not routinely reposition her and that she had to use the call button every two to three hours to request assistance. Staff confirmed the presence of blanchable redness, and the pillow used for positioning was not adjusted to relieve pressure. The resident stated she never refused repositioning, although she experienced anxiety during the process.
Failure to Maintain Physician Orders for BiPAP Parameters
Penalty
Summary
The facility failed to ensure that physician orders for BiPAP parameters were in place for a resident with respiratory concerns and ALS. During interviews and observations, the resident expressed uncertainty about whether oxygen was being bled into her BiPAP, and no oxygen tank was found in her room. Staff confirmed that the BiPAP machine did not have oxygen bled into the system and were unable to locate the oxygen parameter order in the resident's records. Review of the electronic health record revealed no physician's order for the BiPAP parameters, which should include oxygen delivery (FiO2), EPAP, IPAP, and respiration rate. Further review of a physician's order from the resident's clinic indicated specific instructions for oxygen therapy and BiPAP use, but staff demonstrated confusion regarding the meaning of 'hs' in the order and whether the parameters needed to be entered into the electronic record. The resident's baseline care plan did not document the BiPAP parameters or address her frequent anxiety and air hunger related to her ALS diagnosis.
Failure to Limit PRN Psychotropic Medication to 14 Days
Penalty
Summary
The facility failed to ensure that PRN psychotropic medications were limited to 14 days as required by federal regulations. A resident was prescribed diazepam 5mg to be taken every eight hours as needed, beginning on 10/2/24, without a stop date indicated in the physician's order. Medication administration records showed that the resident received PRN diazepam on 23 occasions in both October and November 2024, and the order remained active as of 12/4/24. There was no documentation in the resident's medical record of an initial evaluation or any re-evaluation of the ongoing need for PRN diazepam during this period. Staff interviewed were unaware of the missing stop date and only planned to address it after the issue was identified during the survey.
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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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