Blackfeet Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Browning, Montana.
- Location
- 728 S Government Sq, Browning, Montana 59417
- CMS Provider Number
- 275133
- Inspections on file
- 22
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 21 (1 serious)
Citation history
Health deficiencies cited at Blackfeet Care Center during CMS and state inspections, most recent first.
A resident with a history of hematuria, renal failure, anemia, and recent blood transfusions was readmitted from the hospital with discharge instructions to pause apixaban, but the facility failed to obtain admission orders and did not clarify the incomplete anticoagulant order. The resident’s care plan did not address anticoagulant use or monitoring, and staff administered multiple doses of apixaban after readmission. Nursing notes documented blood in the nephrostomy drainage bag on two days without provider notification or intervention, followed by worsening weakness, poor intake, and hypoxia that led to hospital transfer. Hospital records showed the resident had gross hematuria, hypotension, respiratory distress, acute kidney injury, and a critically low Hgb requiring transfusion, and a late entry note acknowledged that the discharge order to hold apixaban had been overlooked.
Inaccurate PBJ staffing data was submitted to CMS after nursing hours were not fully reflected in the quarterly report when compared with staffing schedules and payroll records. An employee responsible for PBJ submission stated she entered the data quarterly, reviewed a copy for errors, and did not compare the submission with the nursing dept schedule.
The facility failed to thoroughly investigate, monitor, and document multiple abuse allegations involving staff-to-resident and resident-to-resident incidents. In one case, a resident reported that a staff member blew marijuana vape smoke in his face, but there was no related nursing documentation or post-incident monitoring. In another case, a resident reported being hit by another resident, was found with a red mark on the head, and was sent to the ER, yet nursing notes for both residents lacked documentation of the incident and follow-up monitoring. In a third case, a cognitively impaired resident with developmental delay was found in another resident’s room while that resident’s hands were being removed from inside the resident’s pants and shirt, after which the resident complained of pain and was sent to the ER; again, nursing notes for both residents contained no documentation of the event or post-incident monitoring, and the investigator did not fully interview or obtain written statements from all involved as required by facility policy.
A facility failed to keep care plans updated for three residents with changed needs. One resident with a suprapubic catheter had no care plan focus for catheter care, catheter changes, or infection monitoring; another resident taking mirtazapine for depression had no care plan details for the medication, nonpharmacologic interventions, depression symptoms, or adverse effects; and a third resident receiving comfort care had no care plan interventions for end-of-life needs, including fear of dying, terminal restlessness, positioning, reorientation, or family education.
A facility failed to ensure required face-to-face physician visits were completed for multiple residents. Several residents went far beyond the required visit intervals, one resident had no dated physician note to confirm compliance, and one resident had 155 days between provider visits. Staff reported the physician did not follow a set resident visit schedule and was unsure whether other providers were assessing residents between visits.
Failure to obtain informed consent for psychotropic meds: A resident was started on an antidepressant and an antianxiety medication without documented consent in the chart. The resident’s representative said she was notified when meds were started or stopped, but the facility did not explain the risks, benefits, or alternatives before initiation, and staff confirmed consent was expected before psychotropic meds were started or changed.
Restricted Visitation Hours: A posted sign and staff interviews showed that residents were limited to visiting hours from 8:00 a.m. to 8:00 p.m., and visitors arriving outside those times were turned away or told to return later. Two residents stated they did not like the limits and believed they should be able to decide when to receive visitors. The admission agreement also stated that residents have the right to visit anyone during visiting hours.
A resident’s MDS was coded to show insulin injections when the physician order was for Ozempic, a GLP-1 used for diabetes and not insulin. The staff member who completed Section N said she coded Ozempic as insulin because it treated diabetes and stated she had not received formal MDS training or was familiar with the RAI Manual. The facility policy on Resident Assessments was not updated to reflect current guidance for distinguishing insulin from non-insulin injectable meds.
A resident with diabetes had persistently elevated blood sugars, including frequent readings above 200 mg/dL and multiple readings over 300 mg/dL. Staff stated the resident’s diabetes was not adequately controlled and that the insulin regimen should have been evaluated for adjustment, but there were no SSI orders and the last insulin change had been made months earlier. A physician visit documented a blood glucose of 205 mg/dL and stated the resident was doing well, despite ongoing high readings and snack intake contributing to poor control.
The facility failed to keep meds, biologicals, and medical supplies secured and removed expired items from storage. A med supply room was found propped open and later unlocked and unsupervised, with needles and syringes left outside a locked cabinet. An opened vial of PPD was past its discard date, and multiple expired blood tubes and Xeroform dressings were also found in the supply room. Staff gave conflicting statements about who checks for expired items, and the facility policy required meds and biologicals to be stored in locked compartments.
Medical Director Not Active in QAPI and Policy Review. The facility failed to ensure the medical director was active in QAPI and in the review, development, and revision of facility policies and procedures. Staff reported the medical director was not always present at QAPI meetings, and the medical provider stated he was not the medical director, worked full-time at another healthcare entity, and saw residents about every other week. The facility did not provide documentation showing the medical director’s involvement, and a QAPI at Risk Meeting document did not list the medical director among the IDT members who attended.
Failure to follow infection control practices during a med pass affected two residents. An LPN prepared and administered meds while wearing gloves without hand hygiene, touched multiple potentially contaminated surfaces, changed gloves without hand hygiene, and entered residents' rooms after touching door handles without performing hand hygiene before medication administration.
The facility did not complete thorough investigations into multiple abuse allegations, failing to interview other residents cared for by the accused staff or assess psychosocial harm for affected residents. In several cases, residents expressed fear, discomfort, or distress following incidents involving staff, but investigations were incomplete and did not follow facility policy.
A resident with dementia, low vision, and hearing impairment was frequently observed wandering, entering other residents' rooms, and displaying combative behavior, but the care plan was not updated with specific interventions. Staff did not conduct a formal assessment of the resident's behaviors, and interventions were inconsistently applied and undocumented, contrary to facility policy requiring individualized strategies for residents at risk of wandering.
A resident with dementia who exhibited wandering and intrusive behaviors did not receive a formal behavioral assessment or individualized interventions. Staff relied on general distractions and were unclear about documented interventions, while the care plan lacked specific strategies to manage or anticipate the resident's actions. The facility's root cause analysis also failed to identify underlying factors or effective interventions for the resident's behaviors.
A resident with a history of diabetes and dementia, identified as high risk for falls, continued to fall due to the facility's failure to conduct root cause analyses. Despite multiple falls, the facility did not complete necessary documentation, and the resident sustained a head injury from a subsequent fall. Staff interviews confirmed inadequate documentation, and the facility's fall prevention policy lacked a root cause analysis step.
The facility failed to implement enhanced barrier precautions for several residents and did not ensure adherence to standard precautions during medication administration via tube feeding. Observations showed a lack of EBP signage and PPE availability, and staff did not wear gowns during high-contact activities. Additionally, a staff member placed medications on an unclean surface without a protective barrier. Interviews revealed a lack of understanding and implementation of EBP among staff.
A facility failed to report the findings of an alleged abuse incident involving a resident to the State Survey Agency within the required five-day period. The resident reported being assaulted by her son outside the facility and was considered an elopement risk. Despite security alerting the charge nurse, the responsible staff member did not submit the investigation report. The resident returned once but then left against medical advice. The facility's policy requires reporting within five days, which was not followed.
A facility failed to protect a resident's dignity and privacy by posting a sign on her door with her name and instructions for her nephrostomy tube bag care. The resident expressed discomfort with the sign, and staff acknowledged it should not have been there.
A facility failed to ensure proper care and documentation for a resident with a nephrostomy tube. The resident required dressing changes, but the facility did not obtain physician orders or document the changes in the medical record. Staff indicated changes were done as needed, while the resident stated they occurred during doctor visits every three months. The facility's policy required more frequent changes and documentation, highlighting a deficiency in care.
Failure to Clarify Anticoagulant Orders Leads to Unnecessary Drug Administration and Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s drug regimen was free from unnecessary drugs when nursing staff did not clarify and correctly implement anticoagulant orders upon the resident’s readmission. The resident had been hospitalized for hematuria, renal failure, and anemia, received multiple blood transfusions, and was discharged back to the facility with an After Visit Summary instructing that apixaban (an anticoagulant) be paused, with no restart date specified. Despite this, the facility’s admission documentation for the readmission date showed no admission orders, and the apixaban order was not clarified with the physician. The medication was restarted and administered after readmission, even though the hospital documentation indicated it was to be paused and later discontinued. Following readmission, the resident’s Medication Administration Record showed that seven doses of apixaban were given. The resident’s care plan, initiated on the readmission date, did not identify any problems, goals, or interventions related to anticoagulant use, safety, or monitoring for side effects. Nursing progress notes documented that the resident had a right-sided nephrostomy with yellow urine drainage on the day of readmission, and then documented blood in the nephrostomy drainage bag on two consecutive days. However, there was no documentation that the provider was notified about the hematuria or that any action was taken in response to this change. Subsequently, nursing notes described the resident as weak, not eating, unable to maintain a sitting position, and having low oxygen saturation that did not adequately improve with increased supplemental oxygen, leading to transfer to the emergency department. Hospital records from that visit showed the resident presented with hypoxia, hypotension, profound weakness, respiratory distress, gross hematuria, acute kidney injury, and a critically low hemoglobin of 6.9 g/dL, and that the resident had received an anticoagulant and required blood transfusions. A late entry nursing note at the facility later documented that the hospital discharge summary had been overlooked, the order to hold apixaban was not implemented, and the resident continued to receive apixaban until readmission to the hospital. The facility’s root cause analysis attributed the event to ambiguity in discharge communication and medication reconciliation workflow and noted that the apixaban order was incomplete and not clarified before administration.
Inaccurate PBJ Staffing Data Submission
Penalty
Summary
The facility failed to ensure the accuracy of staffing data submitted to CMS through the PBJ system for the quarter covering 10/1/25 through 12/31/25. Review of the PBJ Staffing Data Report showed that the facility did not include all nursing staff hours when compared with facility staffing schedules and payroll records for six days in October 2025, six days in November 2025, and three days in December 2025. During an interview on 3/25/26 at 11:10 a.m., staff member B stated she was responsible for submitting PBJ data on a quarterly basis, that she ran a copy of the information and checked for errors after inputting the data, and that she was uncertain why nursing hours were not correctly reflected. Staff member B also stated she did not compare the submitted information with the nursing department schedule.
Failure to Thoroughly Investigate and Document Multiple Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to complete thorough investigations, monitoring, and documentation for multiple abuse allegations. In one incident, a resident reported that a staff member blew marijuana vape smoke in his face. The staff member later admitted to vaping marijuana in the resident’s room. Despite this, the resident’s nursing progress notes for the period following the incident contained no documentation of the event or any post-incident monitoring, and the psychosocial impact assessment tool indicated that no ALERT charting had been done by nursing or social services. In a second incident, a resident sitting in a wheelchair by the nurse’s station told a staff member that another resident had hit him; assessment revealed a red mark on the resident’s head, and the resident was sent to the emergency room at the family’s request. However, nursing progress notes for both the alleged victim and the alleged aggressor for the days following the incident contained no documentation of the incident or any post-incident monitoring. The staff member responsible for the investigation stated that he relied on video footage and interviews with the two residents, but these interviews were only documented in the incident report, and no other staff or residents on shift were interviewed. In a third incident, staff found one resident in another resident’s room and observed the second resident removing his hands from inside the first resident’s pants and shirt; the first resident later stated, “It hurts down there,” and was sent to the emergency room. The first resident had diagnoses including unspecified symptoms involving cognitive functions and awareness, anxiety, depression, cerebral infarct, and was described as having a developmental delay with the mentality of an 8-year-old, while the second resident was cognitively intact based on a BIMS score of 14. Nursing progress notes for both residents for the days following the incident contained no documentation of the event or any post-incident monitoring. The staff member overseeing the investigation acknowledged that he did not document his post-incident checks, did not interview staff on shift or other residents, and no abuse education or protective measures for staff were documented, contrary to the facility’s abuse prevention policy that requires interviews with all involved, retrieval of written statements, and documentation of assessments and monitoring.
Incomplete Care Plans for Catheter Care, Psychotropic Use, and Comfort Care
Penalty
Summary
The facility failed to revise individualized, comprehensive care plans for three sampled residents when their conditions and treatments changed. Resident #5 had a suprapubic catheter, but the revised care plan dated 2/26/26 did not address catheter care, scheduled catheter changes, or monitoring for signs or symptoms of infection related to catheter use. Resident #6’s care plan dated 3/10/26 did not include the use of mirtazapine for depression and did not identify non-pharmacological interventions, signs or symptoms of increased depression, or monitoring for adverse side effects from the medication. Resident #8 was receiving end-of-life/comfort care, but the care plan did not include comfort care as a focus or list interventions related to the resident’s end-of-life needs. The care plan did not address fears about dying, terminal restlessness, positioning for comfort, changes in cognitive status, increased sleeping, reorientation needs, or education of the resident and family related to the dying process. The record also showed a medical visit on 1/9/26 for end-of-life care, during which the family agreed to comfort care measures, and the care area assessment noted the resident had been increasingly agitated, was sleeping more, needed more reorientation, and expressed fear about dying at night.
Physician Visit Frequency Not Maintained
Penalty
Summary
The facility failed to ensure that residents were seen face-to-face by a physician within the required timeframes for 6 of 17 sampled residents. Resident #1’s last documented physician visit was on 6/11/25, resident #3’s was on 6/3/25, resident #6’s was on 6/13/25, and resident #28’s was on 6/2/25; each had not been seen for more than 225 days. Resident #5’s medical visit note was undated, and there was no documentation confirming that this resident had been seen by a physician within the last 60 days. Resident #15 was seen on 7/24/25 and again on 2/26/26, with 155 days between visits, exceeding the required frequency. During interviews, NF1 stated that resident #6 had not seen a physician in the facility for many months and expressed concern because of the resident’s ongoing medical conditions. Staff member N stated he did not have a set schedule for seeing residents and that his visits depended on his hospital schedule; he was unsure whether any other providers assessed residents between his visits. Staff member A stated physicians were expected to evaluate residents when due and document the visit in the medical record.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure resident #6’s representative was provided the information needed to make an informed decision before psychotropic medications were started, including the risks, benefits, and alternatives. During interview, the resident’s representative stated she was notified when medications were started or discontinued, but the facility did not explain the risks, benefits, or alternatives before initiation, and she had sometimes been asked to sign forms without the medications being explained to her. Record review showed resident #6 was prescribed mirtazapine for depression and clonazepam for anxiety, with mirtazapine started on 2/24/26 and clonazepam started on 3/16/26. The pharmacy medication regimen review noted no informed consent in the chart for mirtazapine and that consent was also needed for clonazepam. The electronic medical record contained no documentation of informed consent forms for either medication before they were initiated. Staff interviews confirmed informed consent forms were expected before psychotropic medications were started or changed, and the facility policy stated residents and/or representatives have the right to decline psychotropic medications and that staff and the physician will review the risks of not taking the medication and appropriate alternatives.
Restricted Visitation Hours
Penalty
Summary
The facility failed to honor residents’ right to receive visitors of their choosing at the time of their choosing for 2 sampled residents. During observation, a sign posted above the double doors near the security desk stated, “Resident Visiting Hours 8:00 A.M. - 8:00 P.M.” During interview, one resident stated she did not like the limitations on visiting hours and believed she should be able to have visitors at a time she chose. Another resident stated the facility did not allow visitors outside the posted visiting hours and said she thought residents should be allowed to decide when they have visitors. Staff interviews confirmed the restriction. One staff member stated residents were not allowed to have visitors before 8:00 a.m. or after 8:00 p.m. Another staff member stated visiting hours were between 8:00 a.m. and 8:00 p.m., that visitors were not allowed outside those times, and that if visitors came outside visiting hours they would be told to come back during visiting hours. A third staff member stated the facility did not have a separate visitation policy and that the visiting hours were included in the admission agreement, which stated that all residents have the right to visit anyone during visiting hours.
Incorrect MDS Coding of Injectable Diabetes Medication
Penalty
Summary
The facility failed to ensure accurate coding of medications on the Minimum Data Set (MDS) for one resident. On the MDS with an Assessment Reference Date of 2/7/26, Section N was coded to show 1 injection received in the last 7 days and 1 day of insulin injections received in the last 7 days. However, the resident’s physician orders dated 11/17/25 showed Ozempic, 1 mg subcutaneously every Monday for diabetes. Ozempic is a GLP-1 medication and is not insulin. During interview, staff member C stated she completed Section N of the MDS and acknowledged she coded Ozempic as insulin because it was used to treat diabetes. She also stated she had not received formal training on MDS completion and was not familiar with the RAI Manual. The facility policy on Resident Assessments stated that persons completing any portion of the MDS must sign attesting to the accuracy of the information, and the policy had not been updated to reflect current RAI Manual guidance for distinguishing insulin from non-insulin injectable medications.
Physician Assessment Did Not Address Persistently Elevated Blood Sugars
Penalty
Summary
The facility failed to ensure physician services provided appropriate assessment and adjustment of treatment for a resident with diabetes, resulting in frequently elevated blood sugar levels for resident #15. The resident stated her blood sugars had often been high, sometimes over 300 mg/dL. Staff interviews confirmed awareness that the resident’s blood sugars were frequently above 200 mg/dL and that her diabetes was not adequately controlled. Staff also stated that if blood sugars were frequently above 200 mg/dL, the insulin regimen should be evaluated for adjustment, and that resident #15 should have been evaluated for sliding scale insulin because snack foods were contributing to the elevated readings. Record review showed resident #15 had no sliding scale insulin orders, and the last insulin adjustment was made on 12/8/25. Blood sugar review from 1/30/26 to 2/26/26 showed 47 readings over 200 mg/dL and 4 readings over 300 mg/dL. The medical visit on 2/26/26 documented a blood glucose of 205 mg/dL and noted the resident was doing well, with the endocrine review section left blank. A later review of blood sugars from 2/27/26 to 3/25/26 showed 47 readings over 200 mg/dL and 9 readings over 300 mg/dL, with an increase in readings over 300 mg/dL after the physician assessment.
Improper Storage and Expired Medications/Supplies
Penalty
Summary
The facility failed to ensure that drugs, biologicals, and medical supplies were stored securely and that expired items were removed from use. During an observation, the medical supply room door was propped open with an ice chest and left unsupervised, and later the same room was observed unlocked and unsupervised. In the medication supply room, one vial of Tuberculin Purified Protein Derivative was found with an open date of 1/26/26 and a discard date of 2/25/26. The medical supply room also contained items that were not secured in a locked cabinet, including one box of 25-gauge 1-inch needles and one box of 1 cc, 27-gauge 1/2 inch needles and syringes. Expired supplies were found in the room, including four blue top blood tubes with an expiration date of 1/31/26, three green top blood tubes with an expiration date of 7/31/25, eight green top blood tubes with an expiration date of 12/31/25, and 47 Xeroform petrolatum dressings with an expiration date of 1/2026. Staff interviews indicated one staff member did not check expired medications or supplies, while another stated nursing staff and night shift staff would look for expired items before use. The facility policy stated medications and biologicals are to be stored in locked compartments and multi-dose vials are to be dated and discarded within 28 days.
Medical Director Not Active in QAPI and Policy Review
Penalty
Summary
The facility failed to ensure the medical director was active in his role for QAPI and for the review, development, and revision of facility policies and procedures. During interview, staff member A stated the medical director was not always present at QAPI meetings and that staff member N did not always participate in reviewing and revising the facility’s policies and procedures, though he sometimes did. Staff member A also stated there was a new medical director expected to start in the near future. Staff member N stated he was not the medical director but was the medical provider, that he worked full-time at another healthcare entity, and that he came to see residents about every other week. He also stated he had just gained access to the facility’s EMR. When documentation was requested to show the medical director’s involvement in QAPI activities and policy review, the facility did not provide records before the end of the survey. Review of a QAPI at Risk Meeting document showed the medical director’s name was not listed among the IDT members who attended.
Failure to Perform Hand Hygiene and Proper Glove Use During Medication Pass
Penalty
Summary
Staff failed to follow accepted infection control practices during a medication pass for two sampled residents. During observation, staff member H prepared medications at the medication cart while wearing nitrile gloves but did not perform hand hygiene before putting the gloves on. While wearing the gloves, staff member H touched multiple potentially contaminated surfaces, including the medication cart, computer, computer mouse, personal hair, shirt pocket, medication keys, and door handles, then removed packaged medication cards and bottles and placed them on the cart before preparing medications into a clear plastic cup. Staff member H then removed the gloves, put on a new pair without hand hygiene between glove changes, and continued the medication pass. Staff member H pushed the medication cart to resident #3's room, touched the door handle, entered, and administered medications without performing hand hygiene before giving the medications. After leaving resident #3's room, staff member H removed gloves, performed hand hygiene, and donned a new pair of gloves, then touched the medication cart, computer, and computer mouse while preparing resident #5's medications. Staff member H entered resident #5's room after touching the door handle without performing hand hygiene and administered medications without hand hygiene prior to administration. During interview, staff member H stated she had been educated on proper hand hygiene and acknowledged she should have performed hand hygiene between donning and doffing gloves, prior to administering medications, and between residents.
Failure to Conduct Thorough Abuse Investigations and Assess Psychosocial Impact
Penalty
Summary
The facility failed to conduct thorough investigations into multiple alleged abuse incidents involving several residents. In each case, the staff member responsible for the investigation did not interview other residents who had received care from the accused staff, nor did they assess the psychosocial impact on the affected residents. For example, one resident reported that a staff member refused to change her soiled brief, but the investigation was limited to interviewing CNAs and did not include other residents or an assessment of the resident's emotional well-being. Another resident reported rough and abrupt care, resulting in her being tearful during the investigation, yet no further interviews or psychosocial assessments were conducted. Additional incidents included a resident who was reportedly afraid and hesitant to receive showers after an alleged rough interaction with a staff member, and another resident who felt uncomfortable and believed a staff member may have taken pictures of him during a shower. In both cases, the investigations did not extend to other residents or include any evaluation of the emotional or psychological effects on the residents involved. Documentation also showed that staff education on abuse was not provided immediately following the incidents. In another case, a resident was reportedly sprayed in the face with water by a staff member during a shower, causing distress. The investigation did not include interviews with other residents, a review of the bath schedule, or a direct interview with the accused staff member. The investigation was not updated with findings, and there was no documentation of abuse education for the staff member upon return to work. Across all incidents, the facility's own policy requiring comprehensive investigations and documentation was not followed.
Failure to Update Care Plan for Wandering Behavior
Penalty
Summary
The facility failed to assess and update the care plan with appropriate interventions for wandering for one resident. Despite the resident having a history of dementia, low vision, and hearing impairment, and being observed wandering the halls, entering other residents' rooms, and displaying combative behavior, the care plan was not adequately revised to address these behaviors. Staff interviews revealed that there was no formal assessment of the resident's behaviors, and interventions were inconsistently applied, such as offering a drink or taking the resident outside, without clear documentation or individualized planning. The resident's electronic health record showed a low risk of wandering based on an outdated assessment, despite frequent documented incidents of wandering and intruding on others' privacy. The care plan listed the resident as an elopement risk/wanderer but lacked specific, individualized interventions and did not specify de-escalation strategies. Facility policy required that residents identified as at risk for wandering have care plans with strategies and interventions to maintain safety, which was not followed in this case.
Failure to Assess and Address Behavioral Causes in Dementia Resident
Penalty
Summary
The facility failed to provide appropriate care and services for a resident diagnosed with dementia by not adequately assessing or identifying the underlying causes of the resident's behaviors. The resident was involved in an incident where another resident hit her after she repeatedly opened and closed his door. Staff interviews revealed that there was no formal behavioral assessment process in place, and interventions were limited to working with the physician on medications or providing distractions such as drinks or outdoor time. Staff were unsure if interventions were documented, and the care plan lacked specific strategies for managing or anticipating the resident's behaviors. Record review showed that the resident was consistently wandering, entering other residents' rooms, and displaying combative behavior. The facility's root cause analysis did not identify underlying factors contributing to the behaviors or specify effective interventions. The care plan noted the resident as an elopement risk and wanderer but only listed general triggers such as age, disease, and smoking, without detailing actionable interventions for staff. As a result, the facility did not provide a comprehensive approach to address or prevent the resident's behavioral issues.
Failure to Identify Root Causes of Falls
Penalty
Summary
The facility failed to identify the root causes of falls for a resident, who continued to experience falls, resulting in a head injury from a subsequent fall. The resident, who had a history of Type 2 diabetes and dementia, was identified as being at high risk of falling with a Morse Fall Scale score of 75. Despite this, the facility did not complete the Fall Root Cause Analysis portion of the Post-accident/Follow-up Investigation Form Team Meeting documents for the resident's falls on multiple occasions throughout the year. On one occasion, a staff member was present when the resident attempted to get out of bed and fell, hitting her forehead. The resident sustained a 2x2 egg-shaped bump on the left side of her forehead, and her vital signs indicated elevated blood pressure and low oxygen saturation. The incident was reported to the emergency room, and the resident was transported via ambulance. Interviews with staff revealed that falls were not documented as they should have been, and the facility's policy on managing falls did not include root cause analysis as a step in the fall prevention process.
Failure to Implement Enhanced Barrier Precautions and Adhere to Standard Precautions
Penalty
Summary
The facility failed to implement and follow enhanced barrier precautions (EBP) for four of the sampled residents and did not ensure adherence to standard precautions during medication administration via tube feeding. Observations revealed that residents with urinary catheters and those receiving medications and nutritional supplements via tube feeding did not have EBP signage on their room doors, nor was personal protective equipment (PPE) such as gowns available in or outside their rooms. Staff members were observed not wearing gowns during high-contact activities, such as administering medications and nutritional supplements via enteral feeding tubes, which are activities that require gown and glove use according to the facility's policy. Additionally, during medication administration for a resident, a staff member placed medications and nutritional supplements on an unclean surface without using a protective barrier. The bedside dresser had unidentified, dried spills, and the staff member admitted to not cleaning the surface or using a barrier before placing the items. Interviews with staff members revealed a lack of understanding and implementation of EBP, with some staff unaware of the need for gowns during certain procedures. The facility's policy outlined the need for EBP signage and PPE availability, which was not observed during the survey.
Failure to Report Abuse Investigation Findings Timely
Penalty
Summary
The facility failed to report the findings of an alleged abuse incident involving a resident to the State Survey Agency within the required five-day period. The incident involved a resident who reported being assaulted by her son outside the facility. The resident was considered an elopement risk as she did not sign out of the facility. Security personnel alerted the charge nurse about the incident. During an interview, a staff member revealed that the responsible staff member did not submit the investigation report. The resident's family attempted to bring her back to the facility, but she returned only once and subsequently left against medical advice. The facility's policy mandates that findings of an abuse investigation be reported within five days, which was not adhered to in this case.
Failure to Protect Resident's Dignity and Privacy
Penalty
Summary
The facility failed to protect the dignity and privacy of a resident by posting a sign on the outside of her door that included her name and instructions for the care of her nephrostomy tube bag. The sign instructed staff to check and empty the resident's urine bag every two hours. This was observed on two separate occasions. During interviews, a staff member acknowledged that the sign should not have been on the door, and the resident expressed discomfort with the sign being visible to everyone. The resident mentioned that a staff member, who was no longer at the facility, had put up the sign. Another staff member was unaware of who placed the sign on the door.
Failure to Document and Order Nephrostomy Tube Care
Penalty
Summary
The facility failed to ensure proper care and documentation for a resident with a nephrostomy tube. The resident required dressing changes for the nephrostomy tube, but the facility did not obtain physician orders for these changes. Interviews with staff members revealed that there were no orders for the dressing changes, and the changes were performed as needed or when the resident requested, approximately every two to three days. However, the resident mentioned that the dressing was only changed during doctor visits every three months. The facility's policy required dressing changes every one to three days using a sterile technique, with documentation of the procedure, the resident's response, and a nursing assessment. The review of the resident's physician orders and medical records from the specified period showed no orders or documentation of dressing changes for the nephrostomy tube. This lack of documentation and adherence to the facility's policy indicates a deficiency in the care and services provided to the resident. The facility's failure to document the dressing changes and obtain necessary orders for the nephrostomy tube care contributed to the deficiency identified by the surveyors.
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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