Brendan House
Inspection history, citations, penalties and survey trends for this long-term care facility in Kalispell, Montana.
- Location
- 350 Conway Dr, Kalispell, Montana 59901
- CMS Provider Number
- 275109
- Inspections on file
- 20
- Latest survey
- July 28, 2025
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at Brendan House during CMS and state inspections, most recent first.
The facility failed to prevent severe weight loss in a resident with malnutrition and wounds, despite being identified as nutrition at risk and requiring weekly weights. Additionally, another newly admitted resident was not weighed weekly for four weeks as required by policy, with only one weight documented and evidence of poor intake and frailty.
The facility did not ensure that care plans were comprehensive and up-to-date for several residents, omitting key interventions such as cardiac monitoring, BiPAP/CPAP therapy, oxygen and nutritional supplement use, and assistance with ADLs and mobility. Staff relied on unofficial documents instead of the care plan, and required assessments for seatbelt use were not performed due to documentation system issues.
Staff failed to consistently use proper hair restraints during food preparation, with some not fully covering their hair or lacking beard coverings, and there was inconsistent enforcement of hair covering policies. Additionally, a resident received a meal that was not served at an appropriate temperature, with staff lacking knowledge of safe reheating practices and not using thermometers to verify food safety, contrary to facility policy.
The facility did not complete required evaluations or obtain provider orders for four residents who were self-administering medications. Observations included residents independently using inhalers, having unsupervised pills at bedside, and possessing non-facility packaged medications, despite lacking documented assessments or orders for self-administration. Staff interviews and record reviews confirmed these residents were not approved for self-administration according to facility policy.
Two residents experienced compromised dignity and privacy: one was left in a public area with her clothing bottoms down and an uncovered, full catheter bag visible to others, while another was transported to the shower with his back and buttocks exposed to staff and residents. Staff did not take appropriate measures to ensure privacy in either situation.
A resident experienced a severe weight loss over several months, but the provider was not notified as required by facility policy. Although the family was aware, staff failed to communicate the significant decline to the physician, preventing timely intervention.
A resident who experienced distress after being told by a nurse practitioner that he was dying was unable to access grievance forms or file a grievance anonymously. Staff could not locate grievance forms on the units, and facility policies lacked instructions for anonymous submission. The facility's grievance log did not reflect any grievances filed by the resident after the incident.
A resident was placed in a Broda chair that functioned as a physical restraint, preventing independent mobility and causing significant agitation. Staff used the chair to prevent falls without attempting alternative interventions or obtaining a proper assessment or physician order. The facility lacked a restraint policy and did not document the use of the chair as a restraint in the care plan or medical records.
A baseline care plan was not completed within 48 hours of admission for a resident with lung cancer, pain, and type II diabetes. Staff interviews indicated that care plans were not reviewed or properly initiated, and the resident's baseline care plan lacked essential health information such as cognitive status, ADL status, respiratory needs, and dietary requirements.
Two residents did not have their care plans updated to reflect changes in their condition and physician orders. One resident with severe weight loss received one-on-one feeding and nutritional supplements, but these interventions were not added to the care plan. Another resident had an indwelling catheter removed and new orders for bladder scans and as-needed straight catheterization, but the care plan was not revised to reflect these changes.
A resident with severe weight loss and a care plan requiring meal encouragement and one-on-one support did not receive needed assistance during multiple meals. Staff left meal trays covered and out of reach, failed to offer alternatives, and removed untouched trays without providing help, despite the resident expressing hunger and the care plan outlining specific interventions.
A resident admitted with an unstageable pressure injury to the right heel did not receive consistent wound care, including proper cleansing during dressing changes and regular wound assessments. Staff demonstrated inconsistent knowledge of wound care protocols, and documentation of wound measurements and care plan updates was incomplete, contrary to facility policy.
A resident receiving enteral nutrition experienced complications due to improper tube feeding management, including use of an alternate formula without a physician order or notification, inaccurate documentation, and failure to obtain required weights despite recent weight loss. Staff also failed to use appropriate PPE and did not follow facility policy for handling feeding equipment and monitoring.
A resident with terminal lung cancer was observed using oxygen therapy without a physician's order in place. Staff confirmed that it is their responsibility to obtain such orders, and facility policy requires a provider order before initiating oxygen therapy. However, review of records showed no order for oxygen use during the relevant period.
Staff did not consistently follow infection prevention and control protocols during wound care, suctioning, and tube feeding for several residents. Observations included failure to perform hand hygiene, improper glove changes, and not wearing gowns as required by Enhanced Barrier Precautions. These lapses occurred despite staff awareness of facility policies and recent training.
Two residents did not receive proper assessment or administration of pneumococcal vaccines as per CDC guidelines. One had consented to all immunizations but did not receive the recommended follow-up vaccine, while another had no vaccination history or consent documented and was not asked about vaccines on admission. Staff were unclear on current vaccine recommendations, and facility policy was not consistently followed.
Facility staff failed to comply with hair restraint protocols during food preparation, with observations showing improper or absent use of hairnets and beard nets. Despite education efforts, staff continued to not fully cover their hair, increasing the risk of contamination.
Two residents experienced significant and severe weight loss without proper notification to their physicians or families. One resident lost 5.09% of their weight in a month, while another lost 17% over six months. Despite facility policy requiring notification of such changes, no documentation was found to indicate that the necessary parties were informed.
The facility failed to ensure proper hand hygiene during meal service and a blood draw, with staff members not washing hands or changing gloves between resident interactions. Laboratory personnel also neglected infection control practices during a blood draw in the dining room. These actions violated the facility's hand hygiene policy and CDC guidelines, putting residents at risk for infection.
A resident's privacy was compromised during a blood draw conducted in an open dining room, with other residents present. The resident was confused and not given a choice to move to a private area. Laboratory personnel did not use proper infection control practices, as one was barehanded while handling supplies and blood vials. The resident expressed distress and confusion about the procedure and personnel involved.
Two residents experienced issues with meal provision, leading to severe weight loss for one. A resident with CHF faced delays in receiving breakfast, while another on a puree diet refused meals, resulting in significant weight loss. Staff disorganization and lack of dietary preference discussions contributed to these deficiencies.
Two residents in the facility experienced tube feeding administration errors, with one resident receiving the wrong formula and another receiving an additional bolus. Staff acknowledged the errors and attributed them to the similarity in appearance of supplies, despite labeling efforts. There was a lack of recent staff training on tube feeding procedures.
A facility failed to report an alleged abuse incident involving a resident within the required 24-hour period. The incident was reported two days late, preventing timely protective measures. A staff member noted the resident's concern about rough handling but did not report it immediately. Facility policy requires reporting such incidents within 24 hours, but this was not adhered to, resulting in a deficiency.
A resident reported being injured by a staff member during care, and the accused staff member was reassigned to other residents instead of being removed from care duties. The facility's policy requires immediate protection for residents, including suspending the accused employee, but this was not implemented, leading to a deficiency in resident protection.
Failure to Prevent Severe Weight Loss and Incomplete Weekly Weights for New Admission
Penalty
Summary
The facility failed to prevent severe weight loss in one resident and did not complete required weekly weights for a new admission. One resident experienced a 9% weight loss in one month, dropping from 132 lbs. to 120 lbs., despite being identified as nutrition at risk (NAR) and having a diagnosis of malnutrition and wounds. Staff interviews revealed that the resident was receiving supplements and was under supervision during meals, but there were issues with meal assistance, care plan updates, and consistent monitoring. The resident had a history of progressing dementia, difficulty swallowing, and required speech therapy, with documentation indicating that weekly weights were ordered but not consistently obtained. Another resident, who appeared thin and frail and was receiving oxygen, was not weighed weekly for four weeks after admission as required by facility policy. The resident reported a decreased appetite and was provided with nutritional supplements, but did not always consume them. Review of the medical record showed only one documented weight during the initial four-week period, contrary to the facility's policy that mandates weekly weights for new admissions to establish a baseline.
Failure to Implement and Update Comprehensive Care Plans for Multiple Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that addressed all identified needs for several residents. For one resident with a cardiac pacemaker, the care plan did not include any mention of cardiac monitoring, despite documentation in hospital records and nursing notes indicating the presence and management of a pacemaker and related monitoring equipment. Another resident who used BiPAP therapy for respiratory issues and experienced increased nighttime anxiety did not have interventions listed for BiPAP/CPAP therapy in the care plan, nor was the presence of a nighttime sitter documented, even though the resident continued to employ a private caregiver overnight. Additionally, a resident with terminal lung cancer who used continuous oxygen and received nutritional supplements did not have physician orders for these interventions, and the care plan lacked focus, goals, or interventions for oxygen or supplement use. Observations confirmed the use of oxygen and the presence of nutritional supplements in the resident's room. Another resident who required assistance with activities of daily living (ADLs) and mobility, and who was observed propelling himself in a wheelchair, also did not have these needs addressed in the care plan. Staff interviews revealed reliance on separate paper documents rather than the official care plan for guidance on resident care needs. The facility also failed to implement care planned assessments for seatbelt use for a resident in a wheelchair. Although the care plan specified quarterly assessments to ensure the resident could unbuckle the seatbelt and that it was functioning for positioning, these assessments had not been completed since a change in the electronic health record system, due to the absence of a template. Staff interviews confirmed that physician orders for seatbelt use were obtained only once and that there was no specific facility policy for seatbelt use.
Failure to Ensure Food Safety and Proper Hygiene During Meal Preparation and Service
Penalty
Summary
The facility failed to ensure proper food safety and hygiene practices in the kitchen and during meal service. Multiple staff members were observed not wearing appropriate hair restraints while preparing food, including hair nets that did not fully cover hair, lack of beard coverings, and staff entering the kitchen without any hair covering. Staff interviews revealed a lack of awareness and inconsistent enforcement of the facility's hair covering policy, with some staff unaware of the requirements and others acknowledging difficulty in monitoring compliance due to high turnover. Signage reminding staff to wear hair coverings had been removed, and the kitchen doors were routinely propped open, further compromising food safety standards. Additionally, the facility did not provide food at an appetizing or safe temperature for a resident. Observations showed that a resident received breakfast that had been left in the room and later reheated in a microwave, resulting in food that was cold in some areas and described as unappetizing by the resident. Staff responsible for reheating food were unaware of required food temperatures and timelines for safe consumption, and did not use thermometers to check food temperature after reheating. Facility policy required reheated food to reach 165 degrees for 15 seconds, but this standard was not followed. Some staff stated that reheating food was not standard practice and that trays should be refrigerated or replaced if not eaten promptly, but this was not consistently implemented or communicated.
Failure to Assess and Obtain Orders for Resident Self-Administration of Medications
Penalty
Summary
The facility failed to obtain evaluations and provider orders for residents to self-administer medications for four residents. Observations revealed that one resident was using a nebulizer independently without a documented self-administration evaluation or provider order, despite having an active medication order for inhaled treatment. Another resident was observed with a cup of pills left at the bedside, taking medications at his own pace due to swallowing issues, but without an assessment or physician order for self-administration. A third resident with severe cognitive impairment, as indicated by a BIMS score of 7, was found with unsupervised medications at her table and no documented assessment for safe self-administration. The fourth resident brought a bag of assorted, non-facility packaged pills to the nurse, and staff were unaware of their origin; this resident also lacked a provider order for self-administration. Interviews with staff confirmed that the required interdisciplinary team evaluations and provider orders for self-administration were not present for these residents. Facility records and a list of approved residents for self-administration did not include the four residents in question. Documentation review further showed that the necessary assessments and orders were missing from both the electronic health records and paper charts for these individuals.
Failure to Maintain Resident Dignity and Privacy During Care Activities
Penalty
Summary
The facility failed to maintain resident dignity and privacy in two separate incidents. In the first case, a resident was observed napping in the dining room in a wheelchair, with her clothing bottoms pulled down below her knees, exposing her catheter and a full catheter bag without a privacy cover. The resident was positioned facing the dining room and unit entrance, with other residents and staff present, and staff did not address the visible catheter bag or the resident's state of undress. Staff later reported attempting to encourage the resident to put her pants on, but the issue persisted until the resident was eventually taken to her room and assisted in dressing. In the second incident, a resident was assisted by staff onto a shower chair while wearing a hospital gown, leaving his back and buttocks exposed. The staff member then transported the resident out of his room and past the dining area, where multiple residents and staff could see him, without making any attempt to cover the exposed areas. The staff member later acknowledged not checking for exposure, and the resident reported feeling upset and embarrassed by the incident. Facility policy reviewed confirms residents' rights to privacy.
Failure to Notify Provider of Significant Weight Loss
Penalty
Summary
A resident experienced a significant and severe weight loss, losing 60 pounds over six months and 26 pounds in the last month, as documented in the electronic health record. Despite this marked decline, the medical provider was not notified of the weight loss, which prevented the physician from having the opportunity to plan or implement interventions. Interviews with staff revealed that while the resident's family was aware of the weight loss, several staff members were unaware of the extent of the decline, and the responsible staff member admitted to not notifying the physician as required. The facility's policy required that all significant changes in weight be reported to the resident's provider, specifically noting thresholds of 5% in 30 days or 10% in 180 days. The resident had been admitted to the Nutrition at Risk Committee, and a note in the record indicated that the care manager was to notify the provider of the weight loss. However, this notification did not occur, as confirmed by staff interviews and record review.
Failure to Provide Access to Grievance Forms and Anonymous Submission
Penalty
Summary
The facility failed to provide residents with access to grievance forms and the opportunity to file grievances anonymously, as required by regulation. One resident reported being told by a nurse practitioner that he was dying and that his kidney function was severely compromised, which was later contradicted by hospital staff. The resident expressed anger and distress over the incident and attempted to seek answers from facility staff but was unable to obtain any. He stated he was unaware of the existence of grievance forms and had not seen any available in the facility. The resident also indicated that his wife would have preferred to file a grievance anonymously if given the opportunity. Observations and staff interviews revealed that grievance forms and boxes were not present in common areas or on the units, and staff were unable to locate the forms when requested. Some staff members were unsure of the process for handling grievances or how residents could file them anonymously. The facility's policy and resident rights documents did not provide instructions for anonymous grievance submission. A review of the facility's grievance log showed no record of grievances filed by the resident, including after he returned from the hospital and voiced his concerns.
Failure to Prevent Use of Physical Restraint Without Assessment or Alternatives
Penalty
Summary
A resident was observed repeatedly confined to a Broda chair, which was reclined at a 45-degree angle with the footrest elevated, preventing the resident's feet from reaching the floor and making it impossible for the resident to exit the chair independently. The resident was visibly agitated, yelling to be let out, attempting to climb over the arm of the chair, and throwing items onto the floor. Staff interviews revealed that the Broda chair was used to prevent falls, as the resident had a history of falling from a standard wheelchair. However, there was no evidence that alternative interventions for fall prevention were attempted prior to the use of the Broda chair. Review of the resident's care plan and medical records showed no documentation of alternative fall interventions, no assessment by physical therapy for the use of the Broda chair, and no physician order for a restraint. The facility did not have a restraint policy or procedure, as it identified itself as a restraint-free facility. Staff confirmed that the use of the Broda chair was not based on a formal assessment or recommendation, and the resident's agitation was attributed to being confined in the chair.
Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to complete a baseline care plan within 48 hours of admission for one resident, as required. Staff interviews revealed that one staff member did not review or look at the resident's baseline care plan, while another staff member, who oversees care planning, stated that baseline care plans are supposed to be completed within 48 hours and that nursing staff are responsible for initiating and updating them. Record review showed that the baseline care plan for the resident was not filled out and did not include essential information such as cognitive status, ADL status, bowel or bladder status, transfer status, respiratory status (including oxygen use), communication status, mobility device use, or type of diet. The resident had diagnoses of lung cancer, pain, and type II diabetes mellitus. The facility's policy requires that care plans be initiated upon admission and describe the services necessary to attain or maintain the resident's highest practicable well-being.
Failure to Update Care Plans Following Changes in Resident Condition and Orders
Penalty
Summary
The facility failed to update care plans in response to changes in resident conditions and physician orders for two residents. For one resident experiencing severe weight loss, documentation provided to the physician indicated poor appetite, use of nutritional supplements, and staff providing one-on-one assistance with meals. However, the resident's care plan was not updated to reflect the use of one-on-one feeding or nutritional supplements, despite staff interviews confirming these interventions were being provided and the resident was being monitored for nutrition risk due to weight loss. For another resident, physician orders indicated the removal of an indwelling catheter and new orders for bladder scans and as-needed straight catheterization following a voiding trial. The care plan for this resident continued to list risk for infection due to the indwelling catheter and was not updated to include the catheter removal or the new interventions. Staff interviews confirmed that care plans were expected to be updated as resident needs and physician orders changed, and facility policy required care plans to be reviewed and revised accordingly.
Failure to Provide Meal Assistance to Resident Requiring Support
Penalty
Summary
Facility staff failed to provide necessary assistance with meals to a resident identified as requiring encouragement and one-on-one support for eating. Multiple observations showed the resident's meal trays were left covered and out of reach, both while the resident was in bed and seated in a Broda chair. On several occasions, staff members were present but did not offer assistance, encouragement, or alternatives before removing untouched meal trays. Interviews with staff revealed inconsistent understanding of the resident's needs, with some staff stating the resident could feed himself, while others acknowledged he required encouragement and occasional one-on-one help. Staff also cited the resident's comfort care status as a reason for not assisting with meals, despite the care plan indicating interventions such as encouragement to eat and offering substitutes or supplements if intake was low. The resident was noted to have severe weight loss and was being monitored in nutrition at risk meetings. The care plan specifically outlined goals and interventions to address nutritional needs, including ensuring the resident consumed more than 50% of meals and providing alternatives if intake was insufficient. Despite these documented needs and interventions, staff did not consistently implement the care plan, resulting in the resident not receiving necessary care and services related to meal assistance.
Failure to Provide Comprehensive Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide appropriate care and services to prevent the worsening of an unstageable pressure injury for one resident admitted with a right heel wound. During a dressing change, staff did not cleanse the wound before applying a new dressing, and there were no clear wound care orders for cleansing. Staff interviews revealed inconsistent knowledge of wound care protocols, including the use of offloading boots, air mattresses, and repositioning. The resident was identified as being at nutritional risk, and recommendations for wound healing supplements were made, but documentation of consistent interventions was lacking. Review of the resident's records showed incomplete and inconsistent wound assessments, with missing weekly measurements and documentation. The care plan did not reflect any new interventions or changes for wound management since admission, and time frames for monitoring and measuring the wound were not specified. Facility policy required weekly wound assessments and photographs, but these were not consistently documented. The lack of comprehensive wound care documentation and failure to follow established protocols contributed to the deficiency.
Failure to Ensure Proper Tube Feeding Management and Documentation
Penalty
Summary
The facility failed to ensure proper management of tube feeding for a resident, resulting in complications and failure to maintain the resident's weight. During observation, a resident was found with leaking tube feeding, and staff responded without donning appropriate PPE beyond gloves. The staff cleaned the leaked feeding and adjusted the tube, but the process revealed issues with the administration and handling of the feeding equipment. Additionally, the suction container was improperly handled and disposed of in the sink, then returned to the bedside table. Further review showed that the prescribed tube feeding formula, Isosource 1.5, was unavailable for two days, and an alternate formula, Fibersource, was used without a new physician order or notification to the physician. The change in formula was not documented in the resident's orders, and the TAR inaccurately reflected that Isosource was administered. Daily weights, ordered to monitor the resident's status, were not documented as required, despite a recent significant weight loss. The facility's policy required weights to be obtained three times a week, but this was not followed.
Oxygen Therapy Administered Without Physician Order
Penalty
Summary
Licensed nursing staff failed to ensure that a physician's order was in place for a resident's oxygen use. During observation, a resident with a diagnosis of metastatic lung cancer was found lying in bed using oxygen via nasal cannula, with the concentrator set to 1.5 liters. The resident reported using oxygen continuously due to his terminal condition. Staff interviews confirmed that nursing staff are responsible for obtaining physician orders for oxygen therapy and are expected to notify the physician and secure the necessary order when oxygen is needed. However, a review of the resident's physician orders for the relevant period showed no order for oxygen use, despite facility policy requiring a provider order for initiation of oxygen therapy.
Failure to Adhere to Infection Control Practices During Resident Care
Penalty
Summary
Staff failed to adhere to infection prevention and control standards during wound care, suctioning, and tube feeding for multiple residents. In one instance, a staff member performed a dressing change on a resident's right heel without changing gloves or performing hand hygiene between removing the soiled dressing and applying the clean one. The wound was not cleansed prior to dressing, and the staff member did not wear a gown as required by Enhanced Barrier Precautions (EBP). The staff member also left the resident's room without removing gloves, contrary to facility policy. Another resident on EBP had tube feeding and suctioning performed by staff who only wore gloves, omitting the required gown. Staff cleaned up leaked tube feeding and handled suction equipment without donning gowns, and did not follow proper procedures for disposing of suction contents. Observations also revealed that staff did not perform hand hygiene before or after care, or after removing personal protective equipment, as required by facility policy. A third resident receiving wound care had staff who donned PPE but failed to change gloves or perform hand hygiene after touching potentially contaminated surfaces, such as the door and bed linens. Supplies were handled and placed on various surfaces without proper glove changes or hand hygiene. After completing care, the staff member disposed of trash without gloves and did not perform hand hygiene before handling medication cards. Interviews confirmed that staff were aware of infection control policies but did not consistently follow them during care.
Failure to Ensure Pneumococcal Vaccination Assessment and Administration
Penalty
Summary
The facility failed to ensure that residents received, or had the opportunity to receive, the pneumococcal vaccine series as recommended. For one resident, documentation showed that consent for all immunizations, including pneumococcal, was provided by the resident's representative, and the resident had previously received the pneumococcal 23 vaccine. However, there was no evidence that the facility assessed or administered the additional pneumococcal vaccines (pneumococcal 20 or 21) as recommended by the CDC for individuals who have only received the pneumococcal 23 vaccine and for whom more than one year has passed since administration. For another resident, there was no documentation of vaccination history or consent in the electronic medical record, and the resident reported not being asked about vaccinations upon admission. The facility's policy stated that CDC recommendations for pneumococcal immunization would be followed, but staff interviews revealed a lack of knowledge regarding current vaccine recommendations and uncertainty about why vaccinations were missed. These findings indicate that the facility did not consistently follow its own policy or CDC guidelines regarding pneumococcal vaccination assessment and administration.
Non-Compliance with Hair Restraint Protocols in Food Preparation
Penalty
Summary
The facility staff failed to adhere to proper hair restraint protocols during food preparation, as observed on multiple occasions. Staff members were seen with hairnets that did not fully cover their hair, including bangs and hair below buns, while others had no beard nets despite having full beards. This non-compliance with the facility's hair restraint policy was noted during food preparation activities, increasing the risk of hair contamination in food served to residents. Interviews with staff confirmed the lack of compliance with the facility's hair restraint policy, which requires all hair to be covered and beards longer than half an inch to be covered in the kitchen or service areas. Despite education being provided to the kitchen staff, further observations revealed continued non-compliance, with staff members either not wearing hairnets or wearing them improperly, and external personnel entering the kitchen without hair restraints.
Failure to Notify Physician and Family of Significant Weight Loss
Penalty
Summary
The facility failed to notify the physician and family of significant and severe weight loss in two residents. Resident #19 experienced a 5.09% weight loss in one month, which is considered significant. Despite this, there were no notifications to the physician, and the last dietician note was dated over a month before the weight loss was recorded. Staff interviews revealed that the resident required assistance with feeding, including cueing and redirection, and was receiving a nutritional supplement with meals. However, there was no documentation of further interventions or notifications to the physician or family regarding the weight loss. Resident #52 experienced a 17% weight loss over six months, classified as severe. Similar to Resident #19, there were no notifications to the physician or family documented. The last record entry was from February, and although the resident was discussed in Nutrition at Risk meetings, the physicians were not involved in these discussions. The facility's policy requires that significant weight changes be reported to the resident's provider and responsible party, but this was not adhered to in these cases.
Inadequate Hand Hygiene and Infection Control Practices
Penalty
Summary
The facility failed to ensure proper hand hygiene practices were followed by staff during meal service in both common dining areas and resident rooms. Multiple staff members, including staff members E, U, Q, F, and G, were observed not performing hand hygiene after direct contact with residents or their environments. Staff member E, in particular, was noted for repeatedly failing to wash hands or change gloves between assisting different residents, handling food items, and touching various surfaces. This lack of hand hygiene was observed during the delivery and setup of meal trays for several residents, including residents #16, #25, #46, #52, #61, and #70. Additionally, during a blood draw for resident #259, laboratory personnel did not adhere to infection control practices. NF1 and NF2 conducted a blood draw in the dining room without using a barrier between the resident's arm and the pillow, and NF1 handled used supplies without gloves. The laboratory staff did not demonstrate awareness of specific infection control training, although they reportedly followed precaution signs on resident doors. The facility's hand hygiene policy, IPC104, and CDC guidelines emphasize the importance of performing hand hygiene before and after patient contact and after glove removal. However, observations revealed that these protocols were not consistently followed, putting residents at risk for infection. Interviews with staff members A, Z, and FF highlighted a lack of adherence to infection control practices and uncertainty about the training received by laboratory staff.
Privacy Breach During Blood Draw in Dining Room
Penalty
Summary
The facility failed to ensure privacy during a blood draw for a resident, which was conducted in an open dining room. The resident was seated at a table with a tablemate and other residents present when laboratory personnel approached and informed her of a STAT order for a blood draw. Despite the resident's confusion and questioning, the personnel proceeded with the blood draw in the dining room without providing a privacy barrier. The resident's tablemate and another resident observed the procedure, compromising the resident's privacy. Additionally, the laboratory personnel did not adhere to proper infection control practices. One staff member was barehanded while handling used supplies and blood vials, which were placed in open plastic bags on a mobile cart. The resident expressed confusion and distress during a subsequent interview, indicating a lack of understanding about the procedure and the personnel involved. The facility's staff member stated that it was typically up to the resident to decide whether to have procedures done in a common area, but there was no indication that the resident was given this choice or that her comfort was assessed.
Failure to Provide Therapeutic Diets Leads to Severe Weight Loss
Penalty
Summary
The facility failed to provide therapeutic diets to optimize the nutritional status for two residents, leading to severe weight loss for one of them. Resident #25, who has a diagnosis of Congestive Heart Failure and ongoing lower extremity edema, experienced issues with meal delivery and consumption. On the morning of 8/27/24, Resident #25 was not served breakfast in a timely manner, despite multiple requests and the presence of his call light. His breakfast tray remained untouched in the dining room while staff members were disorganized and failed to address his needs promptly. Eventually, Resident #25 only received two pieces of toast for breakfast at around 10:30 a.m., with no other food offered. Resident #41, who was on a puree diet, refused to eat the meals provided, opting instead for cookies and snacks brought by his wife. Despite being on a puree diet, his meal ticket indicated a soft diet, and he expressed dissatisfaction with the texture of the food. Over a three-month period, Resident #41 experienced a severe weight loss of 18.13%. Staff member N had changed his diet to include Benecal protein shakes per his preference but had not discussed his food preferences in detail to understand why he was not eating the provided meals.
Tube Feeding Administration Errors
Penalty
Summary
The facility failed to ensure that residents received tube feedings as ordered, resulting in deficiencies for two residents. Resident #77 was observed with a tube feeding pump that was alarming due to a flow clog, and the pump door was found to be open, preventing proper flow. Staff member Y admitted to not realizing the impact of the open pump door, which led to the alarm. Additionally, resident #77 was given the wrong tube feeding formula, Fibersource HN instead of the prescribed Isosource 1.5, as noted in the resident's electronic health record. Resident #36 also experienced issues with tube feeding administration. The resident received an additional bolus of Fibersource HN and was later given the wrong tube feeding formula, Isosource 1.5 instead of the prescribed Fibersource HN. These errors were documented in the resident's electronic health record, with no adverse effects observed. Staff member Z mentioned that the resident's family was being trained on tube feeding administration, but there had been no recent staff training on tube feeding procedures. The facility identified tube feeding errors starting on 8/8/24 and began discussing corrective options. However, the report does not detail specific actions taken to prevent future errors. Staff member FF acknowledged that incorrect tube feedings were treated as medication errors, and there was a need for additional training due to the recurring errors. The facility's management attributed some errors to the similarity in appearance of the supplies, despite labeling efforts to differentiate them.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an alleged incident of abuse involving a resident within the required 24-hour reporting period. The incident occurred on January 17, 2024, but was not reported to the State Survey Agency until January 19, 2024. This delay in reporting was attributed to a staff member's inaction, which prevented the facility from taking timely measures to ensure the resident's protection. The facility's policy mandates that all staff members are responsible for reporting abuse, and it is the responsibility of the Director of Nursing and Administrator to ensure compliance with this policy. The incident involved a resident who reported to a staff member on January 19, 2024, that she wanted to speak about possible rough handling. The staff member noted this concern but did not report it immediately. During an interview, a staff member confirmed that administration was available on weekends to report incidents, and nurses were mandatory reporters. The facility's policy requires that any incidents of alleged abuse or injuries of unknown origin be reported to the Department of Public Health and Human Quality Assurance Division Certification Bureau within 24 hours after discovery. However, this procedure was not followed in this case, leading to the deficiency.
Failure to Protect Resident During Abuse Investigation
Penalty
Summary
The facility failed to protect a vulnerable resident from potential harm during an abuse investigation. A resident reported being injured by a staff member during a brief change and described the staff as verbally spiteful. The incident was reported to another staff member, who added it to the alert charting. Despite the report, the accused staff member was reassigned to care for other residents, which increased the risk of harm to other vulnerable residents. Interviews with staff and residents were conducted, and a follow-up investigation report was completed. The facility's policy on abuse prevention and reporting requires immediate protection for residents involved in incidents, including the potential suspension of the accused employee. However, interviews with staff revealed a lack of awareness and implementation of this policy. The facility's practice was to reassign the accused staff member rather than remove them from resident care, contrary to the policy. This oversight led to a deficiency in protecting residents during the investigation process.
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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