Eastern Montana Veterans Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Glendive, Montana.
- Location
- 2000 Montana Ave, Glendive, Montana 59330
- CMS Provider Number
- 275144
- Inspections on file
- 21
- Latest survey
- December 10, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Eastern Montana Veterans Home during CMS and state inspections, most recent first.
Staff failed to maintain adequate supervision and follow safe handling protocols, resulting in a resident being left unsupervised and sustaining a hip fracture after being pulled from a wheelchair by another resident, and in a separate incident, two residents engaged in a physical altercation due to lack of supervision.
The facility did not conduct or document thorough investigations for incidents involving resident altercations and staff-to-resident verbal abuse. Required interviews with involved parties and witnesses were not completed or documented, and findings submitted to the State Survey Agency were incomplete or inaccurate, lacking supporting evidence and details as required by facility policy.
A resident on a special care unit was left unattended in bed for several hours without necessary ADL care, resulting in pain, distress, and multiple skin injuries. The resident was found with his arm caught between the mattress and footboard, covered in BM, and exhibiting combative behavior. Two CNAs assigned to the unit failed to provide care or notify nursing staff, leading to their termination for neglect.
A resident with dementia, identified as at risk for elopement, exited the facility unsupervised and was later found by police with a head injury after a fall. Despite a wander guard and prior incidents of wandering, staff failed to follow elopement protocols, including conducting a head count after a door alarm. Gaps in staff training and incomplete adherence to policy contributed to the resident's unsupervised exit and subsequent injury.
During an influenza outbreak, two residents who were roommates remained together after one tested positive for flu and the other was not tested, despite one having a high-risk respiratory condition. Key infection control staff were absent, leading to missing and inconsistent documentation of testing, isolation, and infection mapping, and the facility did not follow its own policies for surveillance and transmission-based precautions.
Nursing staff did not follow the facility's elopement policy, resulting in a resident leaving the facility unattended. After a door alarm sounded, a staff member checked the perimeter but did not perform a required head count and was unaware of the full policy procedures. The resident was later found outside by police, and the incident revealed gaps in staff training and knowledge regarding elopement protocols.
The facility did not have an RN on duty for at least eight consecutive hours per day on multiple occasions, with the DON only on call and no staffing waiver in place. This left all residents without immediate RN availability when needed.
Staff failed to follow sanitary food preparation practices, including not covering facial hair, not covering or dating food items in storage, and not maintaining freezer equipment, resulting in uncovered and undated food, ice buildup in the freezer, and improper storage of produce. These actions did not meet facility policies for food safety and personal hygiene.
The facility did not complete or maintain required PASRR Level One documentation for three residents with significant mental health and cognitive diagnoses. For one resident, a new PASRR was not submitted after a convalescent stay exceeded the approved period, and for two other residents, no PASRR forms could be found despite their qualifying conditions. Staff were unaware of or did not follow procedures for PASRR completion as outlined in facility policy.
A resident was not properly assessed or monitored for smoking safety, repeatedly left the facility property to smoke without signing out as required, and did not receive a complete smoking safety evaluation. Staff were aware of the resident's noncompliance with the sign-out policy, and the facility did not provide a sheltered area for smoking or ensure adherence to its own smoking policy.
Two residents had POLST forms in their medical records that were missing the required date next to the provider's signature, making the forms incomplete. Staff interviews revealed that POLST forms are reviewed at admission and annually, but not at every quarterly care conference, and there is no specific nurse assigned to oversee their completion. Facility policy requires advance directives to be obtained and communicated, but these steps were not fully followed.
Two residents experienced unsanitary and unmaintained living conditions, including persistent urine stains and odors in a bathroom and a growing, unrepaired hole in a wall. Housekeeping staff reported daily cleaning assignments, but observations and interviews revealed that deep cleaning and repairs were not performed as required by facility policy.
A resident admitted with an order for supplemental oxygen due to COPD did not have a baseline care plan developed within 48 hours that included instructions for oxygen therapy. Staff interviews revealed confusion about the baseline care plan process and whether oxygen needs were addressed, resulting in a deficiency for not meeting immediate care planning requirements.
A resident experienced significant weight loss and decreased food intake due to skin irritation and pacing, but the care plan was not updated in a timely manner to include interventions addressing these issues. Although a nutritional supplement was ordered, the care plan did not reflect this or provide strategies for the resident's altered nutrition needs.
A resident was subjected to physical and psychosocial abuse by facility staff, resulting in skin injuries and emotional distress. Despite the resident's resistance, staff forcibly transferred her to the dining room, leading to a struggle. The facility's investigation revealed multiple staff involvement but failed to address root causes or prevent future incidents.
A resident's preference to eat meals in her room was disregarded by staff, who insisted she go to the dining room despite her protests. The resident, who was cognitively intact and independent in eating, had personal reasons for avoiding the dining room. Staff members were aware of her preference but took her to the dining room for breakfast, citing safety concerns after a reported fall. Surveillance footage confirmed the resident's resistance to being taken to the dining room, highlighting a failure to respect her right to self-determination.
A resident expressed grief and fear after her husband's death, but the facility failed to update her care plan to address these issues. A staff member provided emotional support but was unaware of the care plan's deficiencies. The social services director position was vacant, and the staff member was temporarily covering the role. The care plan lacked focus on grief, loss, or loneliness.
A resident grieving the recent loss of her spouse did not receive adequate social services support from the facility. Despite expressing fear about a new roommate and showing visible emotional distress, her care plan was not updated to address her grief. A staff member provided emotional support but did not document these interactions, and the facility failed to implement timely interventions to help the resident cope.
Failure to Provide Adequate Supervision and Safe Resident Handling
Penalty
Summary
Staff failed to provide adequate supervision and follow established policies and procedures to maintain resident safety on a secure care unit. On one occasion, two residents were left unsupervised in the dining room when a staff member left to put dishes away in the kitchen, and another staff member left the area to use the restroom. During this period without supervision, one resident pulled another resident's wheelchair, causing the resident to fall to the floor. No staff were present in the immediate area to intervene or prevent the incident, as confirmed by video footage reviewed by facility leadership. The resident who fell was initially assessed and found to have no injuries, but was later discovered to be in significant pain and was transferred to the hospital, where a hip fracture was diagnosed and surgically repaired. The incident revealed that staff did not adhere to the facility's policies regarding supervision and safe resident handling. Staff interviews indicated that there should have been at least two CNAs present for constant supervision, and that staff are expected to have another staff member replace them if they need to leave the unit. However, these protocols were not followed, resulting in a lapse in supervision. Additionally, after the fall, staff manually transferred the injured resident from the floor to a wheelchair without using a gait belt, despite gait belts being available on the unit and required by facility policy for safe transfers. This manual transfer was performed by supporting the resident under the arms and holding the back of his pants, which was not in accordance with the facility's safe handling policy. A separate incident involved a physical altercation between two other residents on the secure care unit, which also occurred when staff supervision was lacking. In this case, a staff member failed to notify a supervisor before leaving for a lunch break, resulting in residents being left unsupervised and leading to a resident-to-resident altercation. Documentation and interviews confirmed that the staff member did not follow instructions for one-to-one supervision, contributing to the occurrence of the incident.
Incomplete Investigation and Documentation of Reported Incidents
Penalty
Summary
The facility failed to conduct and document complete investigations for multiple reported incidents involving residents and staff. Specifically, for an altercation between two residents in the dining room, the facility's documentation was limited to a single paragraph with no supporting evidence, such as interviews with the involved residents, staff, or witnesses. There were also no documented interventions or analysis to prevent recurrence. Additionally, the findings submitted to the State Survey Agency for this incident were inaccurate, referencing unrelated individuals and omitting the actual residents involved. In another incident involving an allegation of staff-to-resident verbal abuse, the facility's investigation was incomplete, lacking details on which residents were interviewed and their responses, as well as missing interviews with staff witnesses. The facility's own policies require thorough documentation, including interviews and written statements from all involved parties, but these procedures were not followed. Staff interviews revealed that documentation practices were inconsistent, with investigation notes being saved as findings without maintaining separate interview records or templates.
Resident Neglected and Left Unattended, Resulting in Injury and Distress
Penalty
Summary
Facility staff failed to provide necessary ADL care to a resident residing on the special care unit, resulting in the resident being left unattended in bed for an extended period. The resident was found lying on his side at the foot of the bed, with his left arm caught between the mattress and footboard, and was observed to be in significant pain and distress, screaming and crying. The resident was covered in bowel movement, as were the bed, floor, and floor mats, and had sustained skin tears and bruising to his left hand, wrist, and hip, with a large dark-colored mark and indentation likely from pressure. The bed was noted to be elevated except at the foot, and the resident was combative during care, resisting staff assistance. Review of staff witness statements and personnel files revealed that the CNAs assigned to the resident did not provide care from approximately 2:00 a.m. to 7:00 a.m., despite being aware of the resident's needs and distress. One CNA reported not feeling comfortable with the resident due to his behavior and did not inform the nurse of the situation, while the other CNA did not perform any cares during this period. Both CNAs were subsequently terminated for neglect. Facility policy defines neglect as the failure to provide necessary goods and services to avoid physical harm, pain, or emotional distress, and includes recurrent failure to provide incontinence care.
Failure to Prevent Elopement and Ensure Resident Safety
Penalty
Summary
A resident with dementia, identified as being at risk for elopement and wandering, exited the facility through the front doors and left the property unsupervised. The resident was able to access a public road and was later found by police at a nearby apartment complex, having sustained a laceration to the forehead after a fall. The incident was reported to the State Survey Agency, and the resident required hospital evaluation and observation for the injuries sustained during the elopement. Facility records indicate that the resident had a history of wandering behaviors, including previous incidents where the resident attempted to leave the facility or triggered door alarms. The resident had been assessed as at risk for elopement and had a wander guard device placed. Despite these interventions, the resident was able to exit the facility undetected. On the day of the incident, a staff member responded to the front door alarm, briefly scanned the perimeter, but did not see any residents outside and did not conduct a head count as required by facility policy. Interviews with staff revealed gaps in training and adherence to elopement protocols. The staff member who responded to the alarm had not read the facility's elopement policy and was not fully oriented to the procedures. Facility policy required a full head count and further action if a resident could not be located, but these steps were not followed. Documentation and communication with law enforcement regarding the incident were incomplete at the time of the survey.
Failure to Maintain Infection Surveillance and Isolation During Influenza Outbreak
Penalty
Summary
The facility failed to maintain an effective system for communicable disease surveillance and infection control during an influenza outbreak. Two residents who were roommates remained in the same room after one tested positive for influenza, while the other was not tested, despite having a primary diagnosis that placed him at higher risk for respiratory complications. There was no documentation of moving either resident to a different room or of testing the second resident for influenza. The infection preventionist and another key staff member were absent during the outbreak, and infection control responsibilities were delegated to other staff, but there were discrepancies and missing documentation regarding resident testing, isolation, and infection mapping. Record reviews revealed that the infection control binder lacked completed tracking and trending for the outbreak period, and the infection mapping for the relevant month was not done. The facility was unable to provide a complete infection control log for the outbreak period, and available lists did not document testing or isolation actions for the two affected residents. Facility policies required surveillance tools and transmission-based precautions, including private room placement or cohorting for residents with influenza, but these measures were not documented as being implemented.
Failure to Train Staff on Elopement Policy Leads to Resident Elopement
Penalty
Summary
Nursing staff failed to follow the facility's elopement policy, resulting in a resident leaving the facility unattended. On the day of the incident, a staff member received a call from the police department notifying them that a resident had been found outside the facility near an apartment complex. A head count was then conducted, revealing the resident was missing. The staff member who responded to the door alarm did not hear the alarm and did not perform a head count after checking the perimeter, as required by facility policy. The staff member was unaware that a head count was necessary and had not read the facility's elopement policy, despite having received orientation at the start of employment. Review of facility documentation confirmed that the elopement policy required a head count and a facility-wide response when a door alarm was triggered without an identified cause. The resident's nursing progress notes and the facility's timeline indicated that the resident exited through the front doors and was not noticed by staff during the initial response to the alarm. The lack of staff knowledge and adherence to the elopement policy directly contributed to the resident's ability to elope from the facility.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for at least eight consecutive hours per day, seven days a week, as required. Review of the licensed nursing schedules for July and September 2024 revealed that on several specific dates, there was no documentation of eight consecutive hours of RN coverage within a twenty-four-hour period. Staff confirmed that on these dates, there were no RN hours recorded, and the director of nursing (DON) was only on call and did not work the required eight consecutive hours. The facility did not have a staffing waiver in place to cover these absences. This deficiency had the potential to affect all residents who required nursing services, as an RN was not immediately available when needed.
Food Safety and Sanitation Deficiencies in Dietary Department
Penalty
Summary
Staff failed to prepare food in a sanitary manner and did not maintain freezer equipment or ensure proper storage of food items. Observations included a staff member with an uncovered mustache and beard working in food preparation areas, and the same staff member later handling food with multiple uncovered skin tears and scabs on his forearms. The walk-in freezer contained a box with a partially open, undated bag of omelets and an opened, undated bag of pork sausages. There was also significant ice buildup under a compressor fan, with a tray placed to catch ice chunks, and boxes of food stored directly below, some with ice chunks stuck to them. The walk-in refrigerator had uncovered heads of lettuce stored in a colander inside a box on a shelf, which remained unaddressed over multiple days. Staff interviews revealed that there was awareness of the need for beard nets for facial hair longer than half an inch, but this was not enforced. Staff also reported that requests for freezer repairs had been made, but the issue persisted, and the practice of chipping away ice chunks was ongoing. Facility policies required food to be covered, labeled, and dated, and for staff to maintain personal hygiene, including keeping facial hair trimmed and clean, but these standards were not met during the survey period.
Failure to Complete and Maintain Required PASRR Documentation
Penalty
Summary
The facility failed to ensure that Pre-Admission Screening and Resident Reviews (PASRRs) were completed and accurate for three of seventeen sampled residents. For one resident with multiple mental health diagnoses, including dementia with behavioral disturbance, anxiety disorder, mood disorder, major depressive disorder, post-traumatic stress disorder, and suicidal ideations, the PASRR on file was a categorical approval for a convalescent stay, which required a new Level One PASRR if the stay exceeded 29 days. Staff were unaware of this requirement and had not submitted a new PASRR Level One as needed. Additionally, two other residents with documented mental health and cognitive conditions, such as emotional shock, hallucinations, mood disorder, depression, PTSD, cognitive communication deficit, and violent behavior, did not have PASRR Level One forms available in their records. Staff confirmed that PASRRs should have been initiated for these residents based on their diagnoses but could not provide the required documentation or explain why the forms were not completed. The facility's own assessment documentation indicated that PASRRs are to be completed to ensure appropriate placement for residents with cognitive disabilities.
Failure to Assess and Monitor Resident Smoking Safety
Penalty
Summary
The facility failed to properly assess and monitor a resident's safety with regard to smoking. The resident reported going outside to smoke four to five times daily, leaving the facility property due to a no smoking policy, and not signing out as required. Despite being aware of the sign-out policy, the resident consistently did not comply, and staff were aware of this noncompliance. The facility did not provide a sheltered area for smokers, and residents were expected to smoke off property without shelter. Staff interviews confirmed that residents were expected to sign out and store their smoking materials in a weatherproof metal container, but these procedures were not consistently followed. Review of the resident's records showed that the required smoking safety assessment was incomplete, with key areas such as cognitive ability, visual acuity, dexterity, and the ability to safely light and extinguish cigarettes left unassessed. Nurse practitioner and physician notes repeatedly identified the resident as an active smoker but did not address or document smoking safety. The facility's policy required physician consultation for safety restrictions and designated smoking areas, but these were not adhered to, and multiple staff failed to follow the policy over several shifts and days.
Incomplete POLST Forms in Medical Records
Penalty
Summary
The facility failed to ensure that POLST (Physician Orders for Life-Sustaining Treatment) forms were completed accurately in the electronic medical records for two of seventeen sampled residents. Specifically, the POLST forms for these residents were missing the required date next to the provider's signature, which is necessary for the validity of the form and the associated physician order. One resident's POLST indicated a preference for CPR and full treatment, while the other indicated no CPR and selective treatment, but both forms lacked the provider's signature date. A hard copy of one resident's POLST form also showed the same omission. Interviews with staff revealed that POLST forms are reviewed by nursing staff during admission and annually at care conferences, but not at every quarterly care conference. There is no designated nurse responsible for overseeing or reviewing the completion of POLST forms for new admissions; this task is typically handled by the admitting nurse. The provider who completes the POLST form is expected to review it. Facility policies require that advance directives, including POLST forms, be obtained, maintained in the medical record, and communicated to the attending physician and during care planning meetings.
Failure to Maintain Clean and Homelike Resident Environment
Penalty
Summary
Surveyors observed that the facility failed to maintain a clean, sanitary, and homelike environment for two residents. One resident's bathroom was found on multiple occasions to have colored stains and dark brown crusted debris around the edges of the toilet and along the walls, as well as a caked and dried dark yellow substance on the floor that appeared to be urine. A strong odor of urine was consistently present. Despite daily cleaning assignments reported by housekeeping staff, the unsanitary conditions persisted over several days, and staff interviews confirmed that deep cleaning had not been performed in the affected bathroom since the staff member began working at the facility. Additionally, another resident's room had a peeling hole in the wall below the heater near the sink, with paint cracking and lifting from the edges. The resident reported that the hole had been present since admission and appeared to be getting larger, with no attempts by staff to repair or cover it. Facility policy required regular cleaning of housekeeping surfaces and prompt cleaning of body fluid spills, but these standards were not met in the observed cases.
Failure to Develop Timely Baseline Care Plan for Oxygen Therapy
Penalty
Summary
The facility failed to develop a baseline care plan with pertinent, condition-specific information to address a resident's needs within 48 hours of admission. Observations showed that the resident was using a nasal cannula connected to an oxygen concentrator set at two liters, as ordered for a respiratory condition related to COPD. However, review of the resident's care plan indicated that the initiation date for supplemental oxygen was not until several days after admission, and there was no evidence that the baseline care plan included the necessary instructions for oxygen therapy within the required 48-hour timeframe. Interviews with staff revealed uncertainty regarding the process for creating and locating the baseline care plan, as well as whether oxygen treatment information was included in the plan. Facility policy requires that a baseline plan of care be developed within 48 hours of admission to address immediate health and safety needs, including essential healthcare information. The lack of timely and complete documentation in the baseline care plan resulted in the deficiency identified by surveyors.
Failure to Timely Update Care Plan for Significant Weight Loss
Penalty
Summary
The facility failed to update the care plan in a timely manner for a resident who experienced significant weight loss. The resident's weight dropped from 143 pounds to 131 pounds, representing an 8.39% loss over 26 days. Despite this notable change, the care plan was not updated to include interventions to address the weight loss until several months later. The resident was observed to be pacing and unable to sit still due to skin irritation, and reported not eating well because of a rash. A nurse practitioner's note confirmed the resident was not eating or drinking adequately due to being focused on the skin condition. Although a nutritional supplement was ordered, the care plan did not reflect this intervention or include strategies to address the resident's decreased intake related to his skin issues and pacing. Staff interviews revealed that each discipline was responsible for updating their respective sections of the care plan, and updates were typically made after the MDS assessment reference date was added. However, the care plan was not promptly revised to address the resident's acute weight loss or the factors contributing to decreased intake. The lack of timely care plan updates resulted in a failure to implement appropriate interventions to address the resident's nutritional needs during the period of significant weight loss.
Resident Abuse and Neglect by Facility Staff
Penalty
Summary
The facility failed to protect a resident from physical and psychosocial abuse by staff, resulting in skin injuries, fear, and sleep disturbances. The incident involved a resident who was forcibly woken up and undressed by a nurse and a CNA, despite her resistance and verbal objections. The staff insisted on taking her to the dining room against her will, leading to a physical struggle that left the resident in shock and fear for several nights. The resident, who was cognitively intact and had a history of osteoarthritis pain, was accustomed to eating in her room. However, staff decided to move her to the dining room for closer monitoring after a fall. Despite the resident's resistance, staff maintained a firm approach, transferring her to a stationary chair to prevent her from leaving the dining room. Surveillance footage confirmed the resident's resistance and the staff's forceful actions. The facility's investigation revealed that multiple staff members were involved in the incident, yet none intervened or reported the abuse immediately. The resident was left with bruises and emotional distress, fearing the return of the staff involved. The facility reported the incident to the State Survey Agency and suspended the staff, but the investigation failed to address the root causes or prevent future occurrences.
Failure to Honor Resident's Dining Preferences
Penalty
Summary
The facility failed to honor a resident's dining preferences, impacting her right to self-determination. The resident, who preferred to eat meals in her room due to personal reasons related to her husband's past experience in the dining room, was forced to go to the dining room against her wishes. This incident occurred when a CNA and a nurse entered her room, woke her up, and insisted she go to the dining room despite her protests. The resident expressed her discomfort and preference to eat in her room, but staff members did not respect her choice. Staff members involved in the incident were aware of the resident's preference to eat in her room due to her emotional distress associated with the dining room environment. Despite this knowledge, staff member I decided to take the resident to the dining room for breakfast, citing concerns about her safety after a reported fall. The staff maintained a firm approach to get the resident ready for breakfast, disregarding her resistance and preference to remain in her room. Surveillance footage confirmed that the resident was taken to the dining room against her will. The footage showed the resident attempting to leave the dining room and resisting staff efforts to transfer her to a stationary chair. The resident's care plan indicated she was cognitively intact and independent in eating, with a preference to eat in her room. The facility's actions violated the resident's right to self-determination and choice, as outlined in her care plan.
Failure to Update Care Plan for Grieving Resident
Penalty
Summary
The facility failed to review and update a comprehensive care plan for a resident who experienced grief and sorrow following the recent death of her husband. During an observation and interview, the resident expressed fear about a new roommate moving in and shared her emotional distress over her husband's passing. The resident noted that facility staff had not addressed her grief or concerns about a new roommate. A staff member acknowledged providing emotional support to the resident but was unaware that the care plan had not been updated. The facility's social services director had recently left, and the staff member was temporarily fulfilling that role. A review of the resident's care plan, last revised two months prior, showed no focus area or interventions related to grief, loss, or loneliness.
Failure to Provide Grief Support to Resident
Penalty
Summary
The facility failed to provide adequate social services to a resident who was grieving the recent loss of her spouse. During an observation and interview, the resident expressed fear about the possibility of a new roommate moving into the room she shared with her late husband. She was visibly emotional, with tears running down her face, and stated that the facility staff had not addressed her concerns or provided any grief support since her husband's passing. The resident's care plan, last revised in August 2024, did not reflect any updates or interventions to address her emotional distress following her husband's death. A staff member acknowledged providing emotional support to the resident but admitted that these interactions were not documented in the electronic medical record (EMR). The staff member also mentioned that the resident's family was involved in her care and intended to consult them about appropriate services for the resident. However, the facility did not timely identify or address the resident's emotional distress, and the social services department failed to implement necessary interventions to help the resident cope with her grief and loneliness.
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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