Continental Care And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Butte, Montana.
- Location
- 2400 Continental Dr, Butte, Montana 59701
- CMS Provider Number
- 275103
- Inspections on file
- 28
- Latest survey
- March 4, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Continental Care And Rehabilitation during CMS and state inspections, most recent first.
Surveyors found that during ongoing plumbing repairs, one end of the kitchen had large sheets of bare, stained plywood laid over missing tile, with surrounding floor areas showing debris and stains. Staff reported that holes had been dug under the flooring to fix drainpipes over the prior two weeks, and that plastic sheeting and tenting were used to contain dust and construction materials. Staff also stated they used plywood to avoid a tripping hazard and were waiting for new tile to arrive. These conditions did not comply with the FDA Food Code and the facility’s sanitation policy requiring cleanable, sanitary nonfood-contact surfaces and clean food service areas.
The facility did not provide meals at scheduled times, resulting in multiple residents waiting extended periods for food, with some meals arriving late and cold. Staff and residents reported ongoing delays, particularly in certain wings, and documentation showed inconsistencies between posted mealtimes and actual service. Staffing issues and process problems contributed to the deficiency, affecting both dining room and in-room meal delivery.
Staff routinely left medications with residents to take on their own without documented safety assessments or physician orders, and care plans did not address self-administration or monitoring. Some residents had cognitive or psychiatric conditions and were unsure about their medications, while staff showed inconsistent understanding of required procedures. Facility policy required interdisciplinary assessment and documentation, which was not completed.
A resident's POLST form indicated Do Not Attempt Resuscitation, but the EHR incorrectly listed the resident as Full Code/Full Treatment. Staff confirmed that social services are responsible for reviewing POLST forms and ensuring accuracy, and facility policy requires documentation and communication of resident choices, but this was not followed, resulting in a mismatch between the resident's wishes and the EHR.
Surveyors found that prescribers did not provide adequate, patient-specific documentation when declining pharmacist-recommended gradual dose reductions (GDR) for psychotropic medications in three cases. Instead, responses were vague or lacked clinical justification, and staff were unaware of proper documentation requirements, resulting in insufficient records to support continued use of these medications.
Multiple residents were observed smoking unsupervised in unauthorized areas, including a blind resident with a history of unsafe smoking and falls. Staff were aware of ongoing violations but did not consistently enforce the facility's no-smoking policy or monitor residents as required. Smoking materials were kept by residents, care plans were incomplete or not followed, and required safety equipment was not used, resulting in increased risk of fire and injury.
A resident with significant vision loss due to cataracts was not properly assessed for vision needs, as staff failed to identify or document the impairment during care conferences and on the MDS. The resident was unable to read or see her food, yet the assessment inaccurately reflected no vision concerns.
A resident with documented bowel and bladder incontinence did not have these conditions addressed in their comprehensive care plan, despite assessment data and facility policy requiring care planning for incontinence. Staff acknowledged the omission and indicated the care plan may not have been completed.
A resident with impaired vision was unable to access necessary eye care and surgery due to the facility's failure to schedule and maintain appointments and arrange timely transportation. Multiple appointments were missed or canceled without proper communication, leading to the resident being refused by provider offices. Staff interviews revealed confusion over scheduling responsibilities, and the resident's care plan lacked interventions for vision needs.
The facility did not ensure that POLST forms were accurately completed for two residents, with one form missing the correct first name and another lacking the required patient or decision-maker signature. Staff confirmed that these forms should be reviewed for accuracy and completeness upon admission and that code status information should be consistent between the POLST and the EHR.
The facility failed to provide therapeutic meals according to physician orders for two dialysis residents. Observations and interviews revealed that meals were high in sodium, contrary to the prescribed renal diets. Residents reported excessively salty food, and staff acknowledged that therapeutic diet orders were not consistently followed, with meals often served late.
The facility failed to provide scheduled showers for three residents, resulting in deficiencies in hygiene care. A resident was found in a filthy condition with a matted ponytail, while another reported infrequent shower offers, often late at night. A third resident indicated a need for a shower, with records showing no showers since admission. These findings highlight the facility's failure to adhere to scheduled hygiene care.
The facility failed to maintain adequate CNA staffing levels, resulting in residents experiencing long wait times for call light responses and missed showers. Staff interviews and observations revealed that insufficient staffing led to delays in meeting residents' needs, with staff often working beyond their shifts without breaks. The facility's actual staffing ratios did not meet the recommended levels, contributing to the deficiencies in resident care.
A resident in a dementia care unit exhibited aggressive behaviors, including physical altercations with another resident and staff, due to the facility's failure to conduct thorough assessments and implement effective interventions. Despite a history of aggression, the resident's care plan was not updated, and behavioral health services were not adequately pursued, leading to ongoing risks for staff and residents.
A facility failed to adhere to professional standards by administering oxycodone and lorazepam concurrently to a resident with COPD, despite warnings of potential side effects. The medications were given together on multiple occasions, although the resident did not have a condition justifying this practice. Staff interviews confirmed awareness of the risks, yet the practice persisted.
The facility failed to maintain sanitary conditions and proper storage in the kitchen, affecting all residents consuming food prepared or stored there. Issues included staff not wearing hairnets, food stored on the floor, a dirty ice machine, expired and undated food items, and a dirty fan pointed towards the dish pit.
The facility failed to complete baseline care plans within the required 48-hour timeframe for 8 out of 25 sampled residents, leading to potential unmet needs. Interviews revealed that the admitting nurse was responsible for initiating these plans, but the facility's policy was not followed.
The facility failed to complete comprehensive, person-centered care plans for four residents requiring oxygen therapy. The care plans lacked necessary details such as the type of oxygen delivery system, when to administer the oxygen, equipment settings, and monitoring of oxygen saturation levels. Staff were also unsure how to access care plans for some residents.
The facility failed to label oxygen tubing and follow physician orders for oxygen administration for two residents. One resident's oxygen tubing was not labeled, and the oxygen concentrator was set incorrectly. Another resident's oxygen concentrator was set higher than the prescribed amount.
The facility failed to serve meals at a palatable temperature for seven residents receiving room trays. Observations and interviews revealed that hot food was often lukewarm or cold by the time it reached the residents' rooms, with inadequate practices for maintaining food temperature during transport.
The facility failed to adhere to infection control practices and proper PPE use during a COVID-19 outbreak involving two residents. Observations showed that the door to the room of two COVID-19 positive residents was left open, and staff did not perform hand hygiene or change PPE when moving between rooms and handling food trays. Despite documented training, staff claimed to have never been educated on proper PPE use.
The facility failed to address the extended duration of antibiotic use for three residents through its Antibiotic Stewardship Program. Despite being aware of the issue, staff reported that prescribing providers refused to discontinue the medications, which did not align with national guidelines or the facility's policy.
The facility failed to update a resident's care plan after the resident, who was severely cognitively impaired, pulled out their PICC line. Despite multiple attempts to contact the facility for more information, no response was received. The care plan was not revised as required by the facility's policy.
The facility failed to follow a dietician's recommendations for a carbohydrate-controlled diet for a resident, resulting in elevated blood sugar levels. The resident was served a meal with higher carbohydrate content than prescribed, and staff confirmed the meal did not meet the dietary order.
The facility failed to ensure accurate MDS assessments for six residents, incorrectly coding bedrails used for mobility as restraints. Staff interviews revealed a lack of understanding regarding the definition of restraints, leading to discrepancies between actual use and documentation.
Unsanitary Kitchen Flooring During Ongoing Plumbing Repairs
Penalty
Summary
Surveyors identified a deficiency related to unsanitary conditions in the kitchen where food was stored, prepared, and served. During observation, two large four-by-eight-foot sheets of bare plywood were found laid over areas of missing tile on one end of the kitchen floor. The plywood had various black stains and was an uncleanable surface that could not be properly maintained for cleanliness. The surrounding tile floor also had scattered debris and white/gray stains. Staff explained that maintenance had dug holes under the flooring to fix drainpipes and that this construction had been ongoing for approximately two weeks, occurring at night when the kitchen was not in use. Staff reported that plastic sheeting and permanent tenting had been hung around the construction areas to contain dust, sand, and concrete debris. One staff member stated he did not know what else to use to cover the missing tile and wanted to avoid creating a tripping hazard. Another staff member stated the floor would be fixed once new tile arrived, expected in about a week. Review of the FDA 2022 Food Code and the facility’s sanitation policy showed requirements that nonfood-contact surfaces be kept free of dust, dirt, food residue, and other debris, and that all food service areas be kept clean, sanitary, and free from litter and rubbish. The observed conditions in the kitchen did not meet these standards.
Failure to Serve Meals at Scheduled Times Resulting in Delayed and Cold Food
Penalty
Summary
The facility failed to provide meals at the regularly scheduled times for five of twenty-five sampled residents, as evidenced by multiple observations and interviews. Residents reported and were observed waiting for extended periods past posted mealtimes, with some meals being delivered up to two hours late. Several residents were found in their rooms or dining areas without food, despite the posted and documented mealtimes indicating when meals should have been served. Staff confirmed that meal delivery was consistently late, particularly for certain wings, and that food was often cold when it finally arrived. Residents expressed dissatisfaction with the timeliness and quality of meal service, with some stating they were forced to order food from outside sources due to hunger or unpalatable, cold meals. Observations showed residents seated with only drinks for prolonged periods, and some residents, such as one who was hungry but had not eaten, had untouched trays delivered late. Staff interviews revealed that dietary staffing fluctuations and process issues contributed to the delays, and that certain wings routinely received meals after others, resulting in predictable lateness for those residents. Documentation provided by the facility showed inconsistencies between posted mealtimes, the mealtime policy, and actual meal delivery times. Staff acknowledged that meal service was not consistent with the documented schedules, and that recent staffing shortages further exacerbated the delays. The deficiency had the potential to affect all residents in the facility, as the late meal service was observed across multiple units and affected both residents in dining rooms and those receiving room trays.
Failure to Assess and Document Resident Safety for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents were properly assessed and found safe to self-administer their own medications before allowing them to do so. Observations revealed that staff routinely left cups of medications at residents' bedsides or on meal trays, allowing residents to take their medications independently without direct supervision. In several cases, residents did not immediately take the medications, and some expressed uncertainty about the purpose of the medications or the conditions they were treating. Record reviews for the affected residents showed that there were no documented assessments for the safety of self-administration of medications, nor were there physician orders authorizing self-administration in the electronic health records (EHRs). Care plans for these residents did not reference their ability to self-administer medications or outline any monitoring procedures. For example, one resident with impaired cognitive function and another with a diagnosis of major depressive disorder and delusional disorders were both left to self-administer medications without documented evaluation of their capacity to do so safely. Interviews with staff revealed inconsistent understanding of the facility's procedures regarding self-administration of medications. While one staff member believed that no physician order or assessment was required, another stated that both were necessary, along with a risk/benefit discussion. The facility's own policy required an interdisciplinary team assessment, documentation in the medical record, and care plan updates for residents self-administering medications, none of which were found in the reviewed cases.
Failure to Accurately Reflect Resident Code Status in EHR
Penalty
Summary
The facility failed to ensure that a resident's code status was accurately reflected in the electronic health record (EHR) in accordance with the resident's completed POLST form. Upon review, the resident's POLST form indicated a preference for Do Not Attempt Resuscitation, while the EHR incorrectly listed the resident as Full Code/Full Treatment. Staff interviews confirmed that social services are responsible for reviewing and ensuring the accuracy of the POLST upon admission, and facility policy requires that any decisions regarding a resident's choices be documented in the medical record and communicated to the care team. However, this process was not followed, resulting in a discrepancy between the resident's documented wishes and the information available to staff in the EHR.
Failure to Document Rationale for Declining Gradual Dose Reductions of Psychotropic Medications
Penalty
Summary
The facility failed to ensure that gradual dose reductions (GDR) for psychotropic medications were attempted or that adequate, patient-specific rationales were documented when GDRs were not performed for three residents. For one resident with dementia, the pharmacist recommended a GDR for Seroquel, but the prescriber declined with only a general statement that the patient was stable, without further clinical justification. Another resident was on Sertraline, and the prescriber responded to the pharmacist's GDR recommendation with a vague comment that "things look good," lacking any specific rationale for maintaining the current dose. A third resident was receiving Duloxetine, Trazodone, and Provigil, and the prescriber declined the pharmacist's GDR recommendations for all three medications without documenting patient-specific reasons for not attempting dose reductions. Additionally, a staff member interviewed was unaware of the documentation requirements for supporting or declining GDRs and was behind on addressing pharmacy recommendations due to personal issues. The facility's policy requires that residents on psychotropic drugs receive GDRs and behavioral interventions unless clinically contraindicated, with clinical rationales documented when GDRs are not attempted. However, the medical records reviewed did not contain adequate documentation to support the continued use of psychotropic medications at the current doses or to explain why GDRs were clinically contraindicated.
Failure to Enforce Smoking Safety Policies and Supervision
Penalty
Summary
The facility failed to follow its own smoking safety policies and procedures for residents who smoke, resulting in multiple deficiencies. Several residents, including one who is blind and at high risk for falls and injury, were observed smoking unsupervised in unauthorized areas, such as immediately outside the activity room door and on the sidewalk, rather than in the designated smoking area. Staff interviews confirmed that residents regularly smoked in these locations, especially during inclement weather, and that staff were aware of the violations but did not consistently intervene or enforce the rules. Cigarette butts were observed littering the ground around these unauthorized smoking areas, indicating ongoing noncompliance. Residents who smoked were not consistently assessed or monitored according to facility policy. One resident, who was blind and had a history of unsafe smoking behavior and prior property damage, was allowed to keep smoking materials in his possession and was not required to sign out when leaving to smoke. His care plan indicated he was unsafe to smoke independently, yet he continued to do so without supervision. Another resident, who required a smoking apron for safety, was not documented as a smoker in his care plan and was observed smoking without the required apron. A third resident reported never being assessed for safe smoking practices and was also observed keeping smoking materials in his room and smoking in unauthorized areas. Staff interviews revealed a lack of consistent enforcement of smoking policies, with some staff deferring responsibility to others or citing resident noncompliance and belligerence as barriers to enforcement. The facility's written policy stated that no accommodations for smoking or tobacco products would be made and that such products were not permitted on the premises, yet this policy was not followed in practice. These failures occurred across multiple shifts and days, involving several staff members and placing residents and others at risk of exposure to second-hand smoke, fire, and injury.
Failure to Accurately Assess Resident's Vision Needs
Penalty
Summary
The facility failed to accurately assess the vision needs of a resident, resulting in an incomplete comprehensive assessment. The resident reported significant vision deterioration since October 2024 due to cataracts and demonstrated an inability to read or see her food during observation. Despite these issues, staff did not identify or address any vision concerns for the resident during care conferences, and no vision needs were documented or reported on the Minimum Data Set (MDS). The MDS inaccurately indicated that the resident could see fine detail and did not use corrective lenses. Facility policy requires comprehensive assessment of vision needs through direct observation and communication, which was not followed in this case.
Failure to Include Bowel and Bladder Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to implement a comprehensive care plan addressing bowel and bladder incontinence for one resident. Review of the resident's Admission MDS indicated that the resident was always incontinent of bowel and bladder, and the Care Area Assessment Summary showed that bladder incontinence had triggered and should have been included in the care plan. The resident's Baseline Care Plan documented frequent incontinence, but the comprehensive care plan did not reflect this condition. During an interview, a staff member acknowledged that bowel and bladder incontinence should be included in the care plan and noted that the resident was relatively new, suggesting the care plan may not have been completed. Facility policy requires the MDS Coordinator and Interdisciplinary Team to review and revise care plans based on resident condition, but this process was not followed for the resident in question.
Failure to Assist Resident with Vision Care Appointments and Transportation
Penalty
Summary
A resident with deteriorating vision experienced significant barriers in accessing necessary vision care services due to the facility's failure to make and maintain timely appointments and arrange appropriate transportation. The resident reported that several appointments had been made and canceled by the facility without her knowledge or notification to the provider offices, resulting in her being late or missing multiple appointments. As a result, some provider offices refused to see her as a patient, and she was unable to receive recommended cataract surgery after being late to a surgeon's appointment. The resident expressed frustration and distress over her inability to participate in activities she enjoyed and her increasing fear of moving around the facility due to her poor eyesight. Interviews with facility staff revealed confusion and lack of communication regarding who was responsible for scheduling and assisting with outside appointments. The new scheduler was unaware of any upcoming vision appointments for the resident, and other staff members either did not know about the resident's vision concerns or denied responsibility for appointment coordination. Review of the resident's care plan showed no documented goals or interventions related to vision appointments, and progress notes contained minimal references to vision care over a six-month period. This lack of coordination and documentation directly contributed to the resident's unmet vision care needs.
Incomplete and Inaccurate POLST Documentation
Penalty
Summary
The facility failed to accurately complete and maintain Physician Orders for Life-Sustaining Treatment (POLST) forms for two residents. For one resident, the POLST form did not contain the resident's correct first name, as it was neither the resident's first name, middle name, nor a name the resident used. For another resident, the required signature of the patient or their decision-maker was missing from the POLST form that was placed in the electronic health record (EHR). Staff interviews confirmed that social services are responsible for reviewing and ensuring the accuracy of POLST forms upon admission, and that the code status on the POLST should match the EHR and be properly signed.
Failure to Provide Therapeutic Meals for Dialysis Residents
Penalty
Summary
The facility failed to provide therapeutic meals that adhered to physician orders for two dialysis residents. Observations and interviews revealed that the meals served to these residents were high in sodium, contrary to their prescribed renal diets. One resident reported that the soup served was excessively salty, and the meal included a roast beef sandwich and a mix of green and kidney beans, which were left untouched. The resident expressed concerns about managing dialysis with a restricted water intake and reported frequent diarrhea. Another resident also noted the saltiness of the food, which included a turkey sandwich with cheese, soup, and saltine crackers. Both residents had physician orders for a renal diet, which requires low sodium intake. Interviews with staff indicated that therapeutic diet orders were not consistently followed, and meals were often served late. The staff member acknowledged that the food trays were similar and did not align with the specific dietary needs of the residents, including those on renal diets. The report references guidelines from the CDC and FDA, highlighting the importance of limiting sodium intake for dialysis patients to prevent complications such as electrolyte imbalances and diarrhea. The failure to provide appropriate meals as per physician orders represents a deficiency in the facility's dietary management for residents requiring therapeutic diets.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to provide scheduled showers for three of the six sampled residents, leading to deficiencies in hygiene care. Resident #1 was reported to have visited another facility in a filthy condition, with significant body odor and a matted ponytail, raising concerns about potential hair loss. Despite being scheduled for showers twice a week, resident #1 only received four showers in the past 30 days, with one documented refusal. Resident #3 reported that his last shower was on a previous Saturday and expressed dissatisfaction with the timing of shower offers, which were often late at night. His electronic health record (EHR) showed a refusal at 3:00 a.m. on the day of the interview, although he stated he rarely refused showers. Resident #8 indicated a need for a shower and stated she had never refused one. Her EHR showed she was scheduled for showers twice a week, but there was no documentation of a shower since her admission. The record showed a refusal on a day not scheduled for a shower and a 'Not Applicable' status on a scheduled day, indicating a lack of showers since admission. These findings highlight the facility's failure to adhere to scheduled hygiene care, resulting in residents not receiving the necessary showers for maintaining personal hygiene.
Inadequate Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to provide adequate staffing levels, particularly Certified Nursing Assistants (CNAs), as per their own facility assessment recommendations. This deficiency resulted in several residents experiencing prolonged wait times for call light responses, with some waiting over 20 minutes. Residents expressed concerns about the long wait times and insufficient staffing, which affected their ability to receive timely assistance for basic needs such as toileting and showers. Specifically, two residents did not receive showers as scheduled, and multiple residents reported waiting times of up to 40 minutes for call light responses. Interviews with staff members revealed that the facility did not maintain records of call light audits, and staff often worked beyond their shifts without breaks due to high resident acuity and low staffing levels. Staff members expressed that the insufficient staffing made it challenging to meet residents' needs effectively, leading to delays in responding to call lights and completing necessary tasks. Observations confirmed that call lights remained unanswered for extended periods, and staff struggled to manage the workload, often leaving late and without taking breaks. The facility's staffing plan outlined a CNA-to-resident ratio of 1:14, but the actual staffing levels did not meet this standard. On the day of the survey, the facility had a census of 86 residents, with staffing ratios falling short of the recommended levels. The C wing had a ratio of 1:15, while the combined A and B wings had a ratio of 1:37 due to a call-off, significantly exceeding the recommended ratio. This discrepancy between the planned and actual staffing levels contributed to the deficiencies observed in resident care and staff workload.
Failure to Address Behavioral Health Needs Leads to Aggression
Penalty
Summary
The facility failed to adequately address the behavioral health care needs of a resident, leading to aggressive incidents involving other residents and staff. Resident #2, who resided in the dementia care unit, exhibited aggressive behaviors, including punching another resident, resident #15, and attempting to hit staff members. Despite these incidents, the facility did not conduct a thorough root cause analysis or implement effective interventions to manage the resident's behavior. Interviews with staff revealed that resident #2 had a history of aggression, including an incident where he placed his hands near a staff member's neck, yet these behaviors were not adequately documented or addressed. The facility's records showed that resident #2 had been agitated and noncompliant, with documented aggressive behavior on multiple occasions. However, there were no updates to his individualized care plan or assessments conducted following these incidents. The care plan lacked person-oriented activities specific to resident #2, and there was no evidence of pain, fall, or behavioral health assessments being completed after the aggressive incidents. Staff interviews indicated that while there were discussions about the resident's behavior, no formal documentation or follow-up actions were taken to address the underlying issues. Additionally, the facility attempted to arrange behavioral health services for resident #2 but faced challenges in securing appointments. A referral for psychiatric services was not completed, and there was a lack of documentation regarding follow-ups with nursing staff about the resident's behaviors. The facility's inaction and lack of comprehensive assessments and interventions contributed to the ongoing aggressive behavior of resident #2, posing a risk to both staff and other residents.
Concurrent Administration of Opioid and Benzodiazepine
Penalty
Summary
The facility failed to meet professional standards of practice by administering an opioid medication, oxycodone, in conjunction with a benzodiazepine, lorazepam, to a resident. This practice was observed despite warnings about the potential for serious side effects, such as respiratory depression and oversedation, especially given the resident's condition of COPD. Interviews with staff revealed that the nursing staff were aware of the risks associated with administering these medications together, yet the medications were still given concurrently on multiple occasions by a specific staff member. The resident involved did not have a diagnosis that would justify the concurrent administration of these medications, such as a seizure disorder or end-of-life care. Despite the facility's medication administration guidelines and the presence of warnings in the Medication Administration Record (MAR), the medications were administered together on several dates. The facility's documentation showed that the staff member responsible had completed competencies in medication management, yet the practice continued, indicating a failure to adhere to professional standards and facility protocols.
Sanitary and Storage Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions and proper storage in the kitchen, which could affect all residents consuming food prepared or stored there. Observations included staff members not wearing hairnets while in designated areas, food items such as hamburger buns, grape juice, and coffee being stored directly on the floor, and a dirty ice machine with a tan and pink film on its plastic surface. Additionally, expired tortilla shells and undated bread were found, indicating a lack of proper food dating and rotation practices. Further observations revealed that food boxes were also stored on the floor of the freezer, and a dirty fan was pointed towards the dish pit, potentially contaminating clean dishes. Interviews with staff members confirmed these practices, with admissions that bread was not dated, the fan was dirty, and the ice machine was cleaned monthly by the maintenance department. Despite the expectation for staff to wear hairnets past a certain point in the kitchen, multiple instances of non-compliance were noted.
Failure to Complete Baseline Care Plans Timely
Penalty
Summary
The facility failed to complete baseline care plans within the required 48-hour timeframe for 8 out of 25 sampled residents. Specifically, the baseline care plans for residents #44, #50, #53, #54, #58, #59, #61, and #221 were not completed on time. For instance, resident #44's care plan was completed four days after the 48-hour window, while resident #50's care plan was completed 52 days late. Other residents experienced delays ranging from three days to 31 days beyond the required timeframe. Interviews with staff members H and B revealed that the responsibility for initiating the baseline care plans lay with the admitting nurse. Staff member B acknowledged that it was her duty to ensure these plans were completed within the 48-hour period. Despite this, the facility's policy on baseline care plans, which mandates their development within 48 hours of admission, was not adhered to, leading to potential unmet needs for the residents.
Deficiency in Comprehensive Care Plans for Oxygen Therapy
Penalty
Summary
The facility failed to complete comprehensive, person-centered care plans for four residents who required oxygen therapy. Resident #37, who used a nasal cannula at two liters, had a care plan that did not specify whether the oxygen was to be intermittent or continuous, if there was oxygen saturation monitoring, or the type of oxygen equipment used. Resident #58, who used a BI-PAP machine at night and required two to three liters of oxygen, had a care plan that lacked person-centered interventions and did not specify the details of oxygen use. Resident #61, who needed two liters of oxygen at all times, had no focus, goals, or interventions addressing the use of oxygen in her care plan. Additionally, staff were unsure how to access the care plan for Resident #61. Resident #5's care plan also failed to specify the amount of oxygen to be administered or when it should be applied. The facility's policies on comprehensive care plans and oxygen administration were not followed, as the care plans did not include necessary details such as the type of oxygen delivery system, when to administer the oxygen, equipment settings, and monitoring of oxygen saturation levels. These omissions were identified through observations, interviews, and record reviews conducted by the surveyors, highlighting a significant deficiency in the facility's ability to provide adequate respiratory care for residents requiring oxygen therapy.
Failure to Label Oxygen Tubing and Follow Physician Orders for Oxygen Administration
Penalty
Summary
The facility failed to label oxygen tubing when it was changed for two residents and did not follow physician orders for prescribed oxygen amounts for two residents. For resident #5, the physician's orders required the oxygen tubing and storage bag to be changed every Sunday and as needed, with the date labeled. However, during an observation, it was noted that there were no labels on the oxygen tubing or equipment for this resident. Similarly, resident #3's oxygen tubing was not labeled with the date, and the oxygen concentrator was set to one and a half liters per minute (lpm) instead of the prescribed two lpm. Additionally, the resident's care plan and physician orders were inconsistent regarding the oxygen amount, with the care plan indicating four lpm and the physician order indicating two lpm. Observations showed the oxygen concentrator set at one and a half lpm on multiple occasions, and the resident was not observed using the oxygen properly during the survey period. For resident #13, the oxygen concentrator was observed to be set at three lpm, while the physician's order specified two lpm. The facility's policy on oxygen administration states that oxygen should be administered under the orders of a physician. These discrepancies indicate a failure to adhere to physician orders and facility policies regarding oxygen administration and equipment labeling, potentially compromising the residents' respiratory care.
Failure to Serve Meals at Palatable Temperatures
Penalty
Summary
The facility failed to serve meals at a palatable temperature for seven residents who received room trays. Multiple residents reported that their hot food was often lukewarm or cold by the time it reached their rooms. Observations confirmed that the food was transferred from the steam table to a thermal insulated food cart without insulated bases for the plates or lids for the bowls. Temperature measurements of the food served to residents showed that the hot food was not maintained at appropriate temperatures, with some items being significantly below the recommended serving temperatures. For example, one resident's white bean soup was measured at 100.5 degrees Fahrenheit, and another resident's tomato soup was measured at 88.5 degrees Fahrenheit. Staff interviews revealed that there were known complaints about the food temperature, and staff members acknowledged that the food was not always warm by the time it reached the residents' rooms. One staff member mentioned that the facility occasionally conducted test trays but was unsure if the food remained warm by the time it was served at the end of the hallway. The facility's current practices for maintaining food temperature during transport were inadequate, leading to the deficiency in serving meals at a palatable temperature for the residents receiving room trays.
Infection Control and PPE Use Deficiencies During COVID-19 Outbreak
Penalty
Summary
The facility failed to adhere to infection control practices and proper PPE use during a COVID-19 outbreak involving two residents. Observations revealed that the door to the room of two COVID-19 positive residents was left open to the hallway, despite one resident frequently coughing. Staff admitted that the door was left open because the resident did not like it closed, although there were no safety risks necessitating this. Additionally, staff were observed not performing hand hygiene or changing PPE when moving between rooms and handling food trays, despite having attended training sessions on these protocols. Interviews with staff indicated a lack of consistent adherence to infection control practices, with one staff member expressing frustration over the daily struggle to enforce proper hand hygiene and PPE use. The facility's policies on hand hygiene and transmission-based precautions were not followed, as evidenced by staff member L's actions of wearing full PPE in the hallway and not performing hand hygiene between tasks. Despite having documented training on these procedures, staff member L claimed to have never been educated on proper PPE use. The facility also failed to provide a requested COVID-19 policy and procedure document during the survey.
Failure to Address Extended Antibiotic Use
Penalty
Summary
The facility failed to address the extended duration of antibiotic use through its Antibiotic Stewardship Program for three residents. Resident #37 had been taking Methenamine Hippurate for 154 days and Macrobid for 20 days without a specified duration or stop date. Resident #26 had been taking Macrobid for 866 days, also without a specified duration or stop date. Despite being aware of the extended use, staff members reported that the prescribing providers refused to discontinue the medications, which did not align with national guidelines or the facility's policy on antibiotic stewardship. The facility's policy required prescribers to provide complete antibiotic orders, including the duration of treatment, which was not followed in these cases. Resident #4 was prescribed Cefadroxil for osteomyelitis and received the medication for four months. The Medication Regimen Review for this resident did not include any recommendations for changes within the specified timeframe. Although research suggests a longer treatment duration for osteomyelitis, the facility's failure to address the extended use of antibiotics for this resident was noted. The facility's policy on antibiotic stewardship was not adhered to, as the orders lacked the required elements such as start and stop dates or the number of days of therapy.
Failure to Update Care Plan for PICC Line
Penalty
Summary
The facility failed to revise and update a resident's care plan to address a PICC line. During an observation and interview, the resident was found sitting in a wheelchair and was unable to answer questions appropriately. The resident's 5-day MDS indicated severe cognitive impairment. Despite multiple attempts to contact the facility for more information, no response was received. The resident's care plan included goals and interventions for IV medication administration via a PICC line, but the care plan was not updated after the resident pulled out the PICC line, as noted in the nursing notes. The facility's policy on care plan revisions upon status change was not followed, leading to the deficiency.
Failure to Follow Carbohydrate-Controlled Diet
Penalty
Summary
The facility failed to ensure that the food served to a resident followed the dietician's recommendations for a carbohydrate-controlled diet. During an observation, the resident was served a ham sandwich with two slices of bread, potato chips, white bean soup with three packages of saltine crackers, and a fruit cup. The resident reported that his blood sugar had been significantly higher since his admission to the facility and attributed this to the increased carbohydrates in his meals. The dietary order for the resident specified a Regular-Carbohydrate Controlled diet, which was not followed. Staff confirmed that the carbohydrate-controlled meal should have included only one slice of bread and two ounces of meat. The resident's blood sugar readings on the day of the observation were elevated, with an average of 228 mg/dL over a ten-day period.
Inaccurate MDS Assessments for Bedrail Use
Penalty
Summary
The facility failed to ensure that resident MDS assessments contained accurate information for six residents. Observations and interviews revealed that several residents had metal bars attached to their beds, which they used for mobility and repositioning. However, these bars were incorrectly coded as restraints in the residents' MDS assessments. For instance, one resident stated that the bars helped her position herself in bed and did not restrict her movement, yet her MDS assessment indicated daily use of restraints. Similar discrepancies were found in the assessments of other residents, where bedrails used for mobility were inaccurately documented as restraints. Staff interviews further highlighted a lack of understanding regarding what constitutes a restraint, with one staff member admitting to being unsure about the definition of restraints and mistakenly coding mobility bars as such. Additionally, the review of physician orders showed no orders for bedrails for some residents, despite their MDS assessments indicating the use of restraints. This inconsistency between the residents' actual use of bedrails and their documentation in the MDS assessments points to a significant issue in the accuracy of resident assessments. The facility's failure to correctly document the use of bedrails and restraints in the MDS assessments could lead to inappropriate care planning and interventions for the residents involved.
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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