Benefis Senior Services - Grandview
Inspection history, citations, penalties and survey trends for this long-term care facility in Great Falls, Montana.
- Location
- 3015 18th Ave S, Great Falls, Montana 59405
- CMS Provider Number
- 275157
- Inspections on file
- 8
- Latest survey
- August 12, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Benefis Senior Services - Grandview during CMS and state inspections, most recent first.
A staff member did not perform hand hygiene before donning gloves and failed to disinfect a handheld glucometer between uses while conducting blood glucose monitoring for two residents. The device was placed on various surfaces and returned to storage without cleaning, contrary to facility policy and staff knowledge.
Three residents were admitted and began receiving care, including oxygen therapy and, in one case, urinary catheter care and extensive ADL assistance, but their baseline care plans did not include necessary problems, goals, or interventions for these needs. Staff interviews confirmed that baseline care plans were not always comprehensive, omitting key information required for effective and person-centered care.
Surveyors found that several residents received oxygen therapy without provider orders specifying the delivery rate, and there was no consistent documentation or labeling of when oxygen tubing was last changed. Additionally, a nebulizer machine and mouthpiece were observed on the floor next to a trash can, with the mouthpiece touching the floor and covered with used tissues, indicating a lapse in infection control practices.
A resident who received Medicare Part A skilled services was not given the required SNF Beneficiary Notification (CMS-10055) upon discharge from skilled care. Staff confirmed the form was not completed and could not provide a reason for the omission, and facility records did not show evidence that the notification was provided.
The facility did not ensure that PRN psychotropic medication orders were limited to 14 days or had documented rationale for extended use. Two residents had PRN orders for alprazolam and lorazepam that lacked appropriate stop dates or exceeded the 14-day limit, with staff acknowledging the oversight and expressing uncertainty regarding hospice care exceptions.
A resident and their representative were not given written notification of the facility's bed hold policy when the resident was transferred to the hospital, as confirmed by staff and a review of facility policy.
Two residents receiving oxygen therapy did not have this intervention addressed in their care plans, and one resident with a recent aspiration event and documented swallowing difficulties lacked care plan interventions for aspiration risk. Staff confirmed these omissions, despite the needs being identified in MDS assessments.
Two residents experienced multiple falls, but their care plans were not updated to reflect the incidents or to include new interventions based on root cause analysis. Despite established processes for event reporting and fall committee review, care plans remained unchanged after each fall, leaving interventions outdated.
A staff member was observed preparing multiple residents' breakfast trays in the kitchen while wearing a hairnet but not a beard net, despite having facial hair that required coverage according to facility policy. The staff member and other employees confirmed that a beard net should have been worn during food preparation.
The facility failed to respond to call lights in a timely manner for three residents, with documented wait times significantly exceeding the expected seven to nine minutes. One resident reported waiting up to 20 minutes, while another experienced a two-hour delay. A third resident, after waiting over 45 minutes, attempted to move without assistance, resulting in a fall. These delays indicate a failure in the facility's response system.
A resident was discharged from an LTC facility without meeting rehabilitation goals and without necessary home health services in place. The resident, who had a wound/fistula and required multiple medications, was sent home alone, leading to safety concerns and potential medication errors. The facility failed to ensure that physical therapy, occupational therapy, and skilled nursing services were arranged prior to discharge, resulting in a deficiency in the discharge process.
Failure to Follow Infection Control Protocols During Blood Glucose Monitoring
Penalty
Summary
Staff member C failed to follow proper infection control practices during blood glucose monitoring for two residents. Specifically, staff member C did not perform hand hygiene before donning gloves prior to testing a resident's blood glucose. After completing the blood glucose monitoring, staff member C placed the handheld glucometer on various surfaces, including a supply cart and the medication cart, without cleaning or sanitizing the device between uses or after use. The glucometer was then returned to the locked supply room and placed on the charger without being disinfected. Interviews with staff members confirmed that the facility's policy requires the glucometer to be disinfected with appropriate wipes between each resident use and after the last use before returning it to the charger. Staff also acknowledged that hand hygiene should be performed before donning gloves and after glove removal. Despite this, staff member C did not adhere to these protocols, as observed and confirmed during interviews. The facility's policy, last revised in February 2024, clearly outlines these infection prevention requirements.
Failure to Include Essential Needs in Baseline Care Plans
Penalty
Summary
The facility failed to develop and implement baseline care plans that included the minimum necessary instructions to provide effective and person-centered care for three of seventeen sampled residents. Specifically, observations revealed that multiple residents were receiving oxygen therapy, but their baseline care plans did not address problems, goals, or interventions related to oxygen use. One resident, who also had a urinary catheter due to urinary retention and required extensive assistance with activities of daily living (ADLs) because of a cancer diagnosis, did not have these needs reflected in the baseline care plan. Interviews with staff confirmed that baseline care plans were initiated at admission but did not consistently include all required information for continuity of care. Staff acknowledged that areas such as ADLs, pain, urinary issues, falls, psychotropic medications, and oxygen therapy should be included, but these were sometimes omitted. Additionally, staff noted that some aspects of the computer system used for care plan entry needed to be addressed to ensure thorough completion of baseline care plans.
Deficient Respiratory Care: Incomplete Oxygen Orders, Poor Tubing Documentation, and Infection Control Lapses
Penalty
Summary
The facility failed to ensure that oxygen therapy orders for several residents included a specific rate of oxygen delivery. Observations revealed that multiple residents were receiving oxygen via nasal cannula, but their provider orders only specified to maintain oxygen saturation above a certain percentage, without indicating the exact flow rate. In some cases, contradictory orders were present, and staff interviews confirmed that orders often lacked a defined rate, especially when transferred from hospital records. This omission was noted for four residents, with staff acknowledging the issue and attributing it to the electronic medical record systems used. Additionally, the facility did not maintain proper documentation or labeling to indicate when oxygen tubing was last changed for several residents. During observations, none of the oxygen tubing in use had visible dates or labels showing the last change, despite facility policy requiring weekly changes and documentation. Staff interviews revealed uncertainty about where or if tubing changes were documented, and it was noted that a recent staffing mix-up may have contributed to the lack of labeling. A whiteboard in the nurse's lounge outlined the process, but this was not consistently followed in practice. Furthermore, infection control practices were not adhered to regarding respiratory equipment. One resident's nebulizer machine and mouthpiece were observed on the carpeted floor next to a trash receptacle, with the mouthpiece touching the floor and covered with used tissues. Staff confirmed that this did not meet infection control standards and acknowledged that the resident was unlikely to have placed the equipment there independently. The resident had a current order for nebulized albuterol four times daily, indicating frequent use of the equipment.
Failure to Provide Required SNF Beneficiary Notification for Medicare Services
Penalty
Summary
The facility failed to provide the required Skilled Nursing Facility (SNF) Beneficiary Notification, Form CMS-10055, to one of three sampled residents who received Medicare Part A skilled services. During an interview, a staff member confirmed that the notification form was not completed when the resident was discharged from skilled care services and was unable to explain the omission. Review of facility records showed the resident's Medicare Part A skilled services began on 4/10/25 and ended on 5/12/25, but there was no evidence that the required notification form was provided to the resident.
Failure to Limit PRN Psychotropic Medication Orders to 14 Days
Penalty
Summary
The facility failed to ensure that psychotropic medications prescribed on an as-needed (PRN) basis were limited to 14 days unless there was documented rationale for continued use in the medical record. For one resident, an order for alprazolam 0.25 mg to be given nightly as needed did not include a stop date or a 14-day limitation. Staff confirmed that such orders should have a stop date. For another resident on hospice, there were two active PRN orders for lorazepam with a one-year end date, both exceeding the 14-day limit without documented justification in the medical record. Staff indicated uncertainty about the appropriateness of longer PRN orders for hospice residents.
Failure to Provide Written Bed Hold Policy Notification During Hospital Transfer
Penalty
Summary
The facility failed to provide written notification of its bed hold policy to a resident and/or the resident's representative when the resident was transferred to the hospital. During an interview, a staff member confirmed that there was no documentation of the required notification for this hospitalization. Review of the facility's own policy indicated that written notification of the room hold policy is required for residents and/or their representatives.
Failure to Include Oxygen Therapy and Aspiration Risk in Care Plans
Penalty
Summary
The facility failed to develop and implement a person-centered comprehensive care plan addressing all identified needs for two residents who were receiving oxygen therapy and for one resident with an increased risk of aspiration following a recent hospitalization for aspiration and respiratory failure. Observations confirmed that both residents were receiving oxygen via nasal cannula, and interviews with staff and residents revealed inconsistencies in the monitoring and supervision of meals, particularly for the resident with a history of aspiration. Documentation review showed that the Minimum Data Set (MDS) assessments for both residents indicated the use of oxygen therapy, and for one resident, documented swallowing difficulties and a history of aspiration. Despite these documented needs, the comprehensive care plans for both residents did not include problems, goals, or interventions related to oxygen therapy. Additionally, the care plan for the resident with a history of aspiration did not address the increased risk for aspiration or swallowing difficulties. Staff interviews confirmed that these care areas should have been included in the care plans, as identified by the MDS assessments.
Failure to Update Care Plans After Resident Falls
Penalty
Summary
The facility failed to update and revise care plans to reflect actual falls and implement new interventions for two residents following multiple fall incidents. For one resident, despite a documented unwitnessed fall from bed and noted impulsivity, the care plan did not include the fall event, the resident's impulsive behavior, or any new interventions post-fall. Staff interviews revealed uncertainty about the interventions in place and reliance on care plans for guidance, but the care plan remained outdated. For another resident, multiple falls were documented, including incidents where the resident was found on the floor or partially out of bed and wheelchair, with some resulting in injuries. Although the facility had a process for event reporting and a fall committee that met regularly, the resident's care plan was not updated with new interventions after each fall to address the root causes. The care plan only reflected interventions implemented shortly after admission, with no subsequent updates following the documented falls.
Failure to Use Beard Net During Food Preparation
Penalty
Summary
A staff member was observed preparing four individual residents' breakfast trays in the kitchen area while wearing a hairnet but not a beard net, despite having facial hair. During interviews, the staff member acknowledged that a beard net should have been worn, and other staff confirmed that both a hairnet and beard net are required when preparing food if indicated. Review of the facility's Food & Nutrition Services Dress Code policy confirmed that facial hair longer than 1/4 inch must be restrained with a facial hair covering while in food service areas. This lapse in following established sanitary hygiene practices was directly observed during food preparation.
Delayed Call Light Response and Resident Fall
Penalty
Summary
The facility failed to ensure that call lights were answered in an appropriate timeframe for three residents, leading to significant delays in response times. Resident #10 reported waiting up to 20 minutes for assistance, particularly during shift changes or after 6:00 p.m., and noted that staff would sometimes turn off the call light without addressing all her needs. The facility's call history confirmed that eight out of fifteen call light uses for this resident exceeded 15 minutes, with some waits extending up to an hour. Resident #6 also experienced prolonged wait times, with 13 out of 14 call light uses exceeding 15 minutes, including one instance of a two-hour wait. Resident #5 reported waiting over 45 minutes for assistance, and in one instance, attempted to get up without staff help, resulting in a fall. The call history for this resident showed multiple instances of extended wait times, including a 59-minute wait. The facility's expectation for call lights to be answered was stated to be seven to nine minutes, as per staff member A. However, the documented wait times for the residents significantly exceeded this expectation, indicating a failure in the facility's response system. The delays in responding to call lights not only compromised the residents' ability to have their needs met promptly but also contributed to a fall incident for one resident who attempted to move without assistance due to the prolonged wait.
Failure to Ensure Safe Discharge for Resident
Penalty
Summary
The facility failed to provide a safe and orderly discharge for a resident who was sent home alone without meeting his rehabilitation goals. The resident had a wound/fistula, required multiple medications, and needed ongoing rehabilitation services. Despite these needs, the resident was discharged without the necessary home health services in place, increasing the risk of a poor outcome and safety concerns due to his inability to care for himself. Interviews revealed that the resident was discharged without home health services, physical therapy, or occupational therapy being initiated. The family, who lived nearby but were not planning to provide full-time care, had not seen any home health services since the discharge. The resident struggled with mobility, requiring assistance to reach his apartment, and was unable to manage his medications, leading to concerns about potential medication errors. The facility staff member responsible for setting up these services did not follow up to ensure they were in place, and the family was left without support until a scheduled appointment with a new primary care provider. The resident's discharge paperwork lacked instructions for wound care or fistula management, and he had not met several occupational and physical therapy goals necessary for a safe return home. The resident expressed that he did not feel prepared for discharge, and the facility's failure to ensure necessary services were in place prior to discharge put him at risk for negative outcomes. The facility's actions and inactions led to a deficiency in providing a safe discharge process for the resident.
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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