Kalispell Rehabilitation And Nursing Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Kalispell, Montana.
- Location
- 171 Heritage Way, Kalispell, Montana 59901
- CMS Provider Number
- 275025
- Inspections on file
- 27
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 40
Citation history
Health deficiencies cited at Kalispell Rehabilitation And Nursing Llc during CMS and state inspections, most recent first.
A resident with severe dementia and a history of falls was not provided with adequate supervision or individualized interventions to address her wandering and behavioral risks. Despite multiple injuries, including a compression fracture and a fractured hip, the care plan lacked specific strategies for fall prevention and behavioral management. Staff interviews and documentation revealed inconsistent monitoring, insufficient staffing, and a lack of effective interventions, resulting in repeated accidents and injuries.
A resident with severe dementia and a history of wandering and aggression was not provided with adequate supervision or individualized interventions, resulting in repeated incidents of entering other residents' rooms, altercations, falls, and injuries. Care plans were not tailored to the resident's needs, pain management was inconsistent, and required monitoring was not properly documented, leading to distress and harm for both the resident and others.
Residents repeatedly reported issues with inadequate housekeeping and missing laundry items over several months, with concerns documented in Resident Council meetings and confirmed by staff interviews. Despite these ongoing complaints, the facility did not resolve the problems, resulting in continued deficiencies in cleaning and laundry services.
The facility failed to provide a clean and homelike environment and did not properly manage residents' laundry, resulting in persistent cleanliness issues and frequent loss or misplacement of personal clothing. These failures led to repeated resident complaints and an altercation between two residents over misidentified clothing, with staff confirming ongoing problems in both housekeeping and laundry processes.
The facility did not report allegations and findings of abuse within the required timeframes for a resident involved in a physical abuse incident with staff and for two residents involved in a verbal altercation. Delays were attributed to technical issues and failure of staff to promptly report incidents, resulting in late notifications to the State Survey Agency.
A resident with dementia who exhibited aggressive behaviors, wandering, frequent falls, pain, and elopement risk did not have a care plan with specific, person-centered interventions. The care plan relied on vague redirection strategies and lacked individualized pain management, fall prevention, and activity planning. Staff were unaware of the full extent of the resident's behaviors, and meaningful activities were not provided for residents in the memory care unit, resulting in inconsistent and unsafe care and unmet psychosocial needs.
The facility did not provide daily, individualized or group activities for residents with dementia in the secure memory care unit. Observations and interviews with family and staff confirmed a lack of meaningful engagement, with residents often left sitting in silence without activities. Requested documentation of activity participation was not provided, and facility policies requiring special consideration for dementia care were not followed.
A resident with dementia and a diagnosis of wandering was not accurately assessed for daily wandering behaviors on the MDS, as staff did not review all relevant medical diagnoses or interview family members. This led to incomplete documentation and care planning that did not address the resident's actual wandering frequency.
The facility failed to respond to residents' call lights in a timely manner, resulting in inadequate pain management and feelings of insecurity. Residents reported waiting over 30 minutes for assistance, particularly at night, due to understaffing. Staff confirmed insufficient staffing, leading to delays in addressing residents' needs. One resident with multiple health conditions experienced daily pain and inadequate repositioning assistance. The facility's call light audit goal of a 5-minute response time was not met, contributing to resident dissatisfaction.
The facility failed to implement proper infection control measures, including adherence to transmission-based precautions and documentation of COVID-19 testing. Staff entered rooms without PPE, and there was confusion about which residents required contact precautions. Additionally, COVID-19 testing for close contacts was not documented, and the facility lacked a system for monitoring waterborne illnesses.
The facility failed to maintain a clean environment in resident shower areas and did not adequately safeguard residents' personal belongings from loss or theft. Observations showed unclean shower rooms with used washcloths and pooled dirt, while interviews revealed frequent reports of missing clothing and personal items. The facility's grievance process and inventory management were ineffective, with insufficient staff training contributing to the deficiencies.
The facility failed to maintain an effective grievance program, particularly regarding lost resident belongings. Staff interviews revealed inconsistencies in elevating issues to a formal grievance level, and a missing grievance log was noted. A resident discharged with missing items, including an iPad and Apple Watch, had unresolved grievances despite these items being inventoried.
The facility failed to manage pain effectively for several residents, including one with advanced dementia who showed signs of distress without receiving scheduled pain medication. Another resident experienced delays in receiving pain relief, affecting mobility and increasing the risk of skin breakdown. Additionally, a resident reported unmanaged pain with missed assessments, and another was unfamiliar with the pain scale, indicating systemic issues in pain management.
The facility failed to follow up on dental care referrals for several residents, resulting in unresolved dental issues and ill-fitting dentures. A resident had multiple dental concerns identified by a hygienist, but no follow-up was documented. Other residents experienced difficulties eating due to poorly fitting dentures, with one resident experiencing significant weight loss. No documentation of dental appointments was provided.
The facility's dietary department failed to serve meals on time, resulting in cold food for residents. Breakfast and lunch were consistently delayed, with residents reporting dissatisfaction with the food quality. Some residents received meals that did not match their dietary needs, and staff members confirmed the poor quality of the food.
The facility failed to provide adequate supervision in the memory care unit, leading to resident confrontations and unsafe conditions. A resident eloped due to ineffective wanderguard systems, and two residents were improperly positioned during meals, increasing choking risks. Staff shortages and non-compliance with care plans contributed to these deficiencies.
A facility failed to refer a resident for a PASARR Level II assessment after a PTSD diagnosis was added. The resident, with a history of military service and being a prisoner of war, had a PASARR Level I assessment that did not include PTSD. A staff member acknowledged the need for a new Level I assessment, but no Level II request was made before the survey ended.
A facility failed to document a resident's need for enteral tube feeding in their baseline care plan, despite the resident's history of spinal cord injury, Parkinson's, and aspiration pneumonia, and being NPO. The admitting nurse did not include this critical information, and the floor nurse did not complete the care plan, contrary to facility policy.
The facility failed to provide necessary assistance to two residents with activities of daily living (ADLs). One resident, dependent on staff for eating, was observed struggling to feed himself without assistance. Another resident with Parkinson's disease was found struggling to dress herself after using the bathroom, despite needing supervision and assistance as per her care plan.
The facility failed to ensure timely hospice referrals for two residents, resulting in significant delays in care. One resident experienced a delay in hospice referral despite a fall and a request from their POA, while another resident faced confusion over palliative care orders, leading to unmanaged pain and immobility concerns. Staffing issues and lack of a palliative care policy contributed to these deficiencies.
A facility failed to provide necessary treatment for a resident diagnosed with PTSD. The resident, a veteran with a history of combat and imprisonment, expressed the need for psychiatric or counseling services. Despite the diagnosis, no referral for treatment was made, and staff confirmed the lack of action. No documentation was provided to show any referral for PTSD treatment.
The facility did not follow the posted menus for two out of three observed meals, serving different items than those listed. This included missing whole grain toast at breakfast and serving an entirely different lunch menu, potentially affecting residents relying on the posted menus for their nutritional needs.
The facility failed to adhere to physician-ordered therapeutic diets for three residents. A resident on a CCHO diet reported high blood sugar levels due to inappropriate meal content, while another had to remind staff to provide sugar-free syrup. A resident with end-stage renal disease was not provided a renal diet, and staff were unaware of specific dietary needs. Budget constraints and lack of awareness contributed to these deficiencies.
A resident did not receive two prescribed medications, Cefdinir and Potassium Chloride, during an evening medication pass, resulting in a 6.4% medication error rate. Staff interviews confirmed that the absence of documentation in the MAR indicated a medication error. The facility's policy requires timely administration and documentation of medications, which was not followed in this instance.
A significant medication error occurred when a staff member in an LTC facility pre-poured medications and mistakenly gave a resident high-dose opioids instead of Tylenol. The staff member failed to follow the facility's medication administration procedures and did not monitor the resident's health adequately after the error. The resident was found unresponsive and required hospital treatment for an opioid overdose.
A LTC facility failed to prevent significant medication errors for two residents, leading to an Immediate Jeopardy situation. A resident was mistakenly given high doses of opioids instead of Tylenol, resulting in an opioid overdose and hospitalization. Another resident received an incorrect dosage of Trospium due to a transcription error, although no adverse effects were reported. The facility's medication administration and error monitoring policies were not adequately followed, contributing to these errors.
A resident was given incorrect medications, leading to an opioid overdose and hospitalization. The facility also failed to assess two residents' ability to consent to sexual contact, resulting in an incident in the memory care unit. Additionally, a resident-to-resident abuse event occurred when a wandering resident was pushed, causing a fall.
The facility failed to protect two residents from falls and hazards, resulting in multiple injuries. One resident experienced eight falls in 17 days, with significant injuries, while another was pushed by a fellow resident due to wandering. Staff were unaware of care plan updates, and interventions were not effectively communicated or enforced, leading to inadequate supervision and safety measures.
A facility failed to report a medication error leading to a resident's medical neglect and an incident of inappropriate sexual contact between two residents. The medication error involved incorrect administration of Vicodin and OxyContin, resulting in the resident becoming unresponsive and requiring Narcan. Additionally, two residents were found in a potentially nonconsensual sexual situation, but their capacity to consent was not assessed, and the incident was not reported to the State Survey Agency.
A facility failed to investigate a significant medication error where a resident was given incorrect medications, leading to unconsciousness and hypoxia. The investigation lacked input from key personnel and did not include education for other nurses. Additionally, the facility did not assess the capacity to consent in a sexual contact incident between two residents, leading to ongoing inappropriate behaviors affecting another resident. The facility's policy on abuse prevention was not followed, as no assessments were conducted prior to the incident.
The facility failed to maintain a clean environment, affecting twelve residents. Observations revealed unclean rooms with dried food, dust, and feces on toilet seats. Residents reported infrequent housekeeping, with some rooms cleaned only once a week. Staff interviews confirmed understaffing in housekeeping, and grievance reports showed ongoing concerns about cleanliness and supply refills.
The facility failed to provide a structured activities program for residents in the memory care unit, as observed and reported by staff and a resident. Interviews revealed inconsistencies in activity provision, with some staff noting limited engagement in activities like coloring and television, while others confirmed the absence of structured activities and an activities aide since November 2023.
A staff member failed to prime an insulin pen before administering insulin to a resident, contrary to the facility's policy. The staff member, on her first day at the facility, was unaware of the priming process. The facility's policy requires a 2-unit dose of insulin to be released as an air shot before each use.
A resident admitted for rehabilitation experienced inadequate care, including long wait times for assistance, lack of help with repositioning and toileting, and poor hygiene management. The resident was discharged with open sores and feeling mistreated, highlighting a failure in meeting care needs despite having a care plan in place.
A staff member failed to perform proper hand hygiene and use protective measures during medical procedures for a resident. She did not sanitize her hands or don gloves during blood glucose monitoring, insulin administration, or the administration of eye drops. Additionally, she placed the glucometer on the resident's table without a barrier and failed to clean it after use, contrary to facility policy.
The facility failed to ensure a clean environment for 10 of 14 sampled residents, leading to feelings of discouragement and frustration. Observations revealed soiled diapers, dirty floors, and food wrappers. Staff interviews indicated housekeeping was short-staffed, resulting in uncleaned rooms. One resident's room had crumbs, debris, a soiled bed pad, and a broken sink handle, with complaints unaddressed.
A facility failed to implement care planned fall interventions for a resident at risk for falls. The resident was found on the floor without footwear, in a dimly lit room, and without non-slip strips or a fall mat. Staff interviews revealed various reasons for the failure, including the removal of the fall mat and a delay in applying non-slip strips.
A resident with a history of falls and severely impaired cognition experienced multiple falls due to the facility's failure to implement fall prevention interventions. The resident was found on the floor in a dimly lit room with wet urine and no non-skid strips or fall mat. Staff inconsistencies and lack of communication contributed to the failure to follow the resident's care plan.
Failure to Provide Adequate Supervision and Fall Prevention for Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and monitoring for a resident with a significant history of falls and cognitive impairment. The resident, who resided in the memory care unit and had severe dementia, was known to wander frequently and had altercations with other residents. Despite being identified as a high fall risk with previous injuries, the care plan did not include sufficient or specific interventions to address her safety needs, wandering behavior, or fall prevention. The care plan goals were unrealistic given her cognitive status, and interventions lacked detail regarding her pain management, mobility limitations, and behavioral triggers. Multiple incidents were documented where the resident sustained injuries, including a compression fracture and a fractured hip requiring surgery. These injuries resulted from both witnessed and unwitnessed falls, as well as altercations with other residents. Progress notes and staff interviews revealed that supervision was inconsistent, and staff were often unaware of the resident's whereabouts. There was a lack of documentation regarding the direct causes of falls, the effectiveness of interventions, and whether appropriate supervision was in place at the time of each incident. Staff reported being too busy to provide adequate oversight, and 1:1 observation, when implemented, was not maintained as a long-term intervention. The facility's policies required systematic monitoring and management of residents at risk for elopement or unsafe wandering, but these were not effectively implemented for this resident. The care plan did not address specific needs such as toileting schedules, safe wandering paths, or individualized behavioral interventions. Staff interviews confirmed that interventions were limited to redirection, and additional measures such as visual cues or environmental modifications were not consistently used. The lack of adequate supervision and failure to implement effective, individualized interventions directly contributed to the resident's repeated falls and injuries.
Failure to Provide Adequate Supervision and Individualized Dementia Care
Penalty
Summary
A resident with severe dementia, poor safety awareness, and a history of aggressive behaviors and wandering was admitted to the memory care unit. The resident exhibited continuous wandering, entered other residents' rooms, displayed aggression, and had multiple falls, some resulting in significant injuries such as a hip fracture and a compression fracture. Despite being identified as high risk for elopement and falls, the resident was not consistently provided with individualized interventions or adequate supervision to address her specific behavioral and safety needs. Documentation showed that staff were often unaware of her whereabouts, and interventions such as 1:1 observation were implemented only temporarily and not maintained, even though staff reported these measures were effective in ensuring safety. The care plans developed for the resident were not sufficiently individualized or tailored to her needs. Goals set for the resident, such as developing coping skills for cognitive decline, were unrealistic given her severe cognitive impairment. Interventions lacked specificity, and there was no clear plan for managing her pain, which may have contributed to her behaviors. The care plan also failed to identify patterns in her wandering or provide detailed strategies to prevent her from entering other residents' rooms. Staff interviews revealed a lack of consistent use of visual cues or other non-pharmacological interventions, and staff expressed concerns about insufficient staffing and supervision. Additionally, the facility failed to consistently administer pain medications as ordered, which was noted by the provider as a concern and may have contributed to the resident's ongoing agitation and behavioral issues. Monitoring tools, such as 15-minute checks, were not completed as required, and documentation was often incomplete or inaccurate. The lack of adequate supervision and oversight resulted in repeated incidents where the resident intruded into other residents' rooms, leading to altercations and injuries, and caused distress and fear among other residents. The facility's actions and inactions did not meet the resident's behavioral, safety, and cognitive needs as required.
Failure to Address Resident Concerns with Housekeeping and Laundry Services
Penalty
Summary
The facility failed to address ongoing concerns raised by residents regarding housekeeping and laundry services, as documented in Resident Council minutes over several months. Residents repeatedly reported issues such as inadequate cleaning of their rooms, particularly toilets and floors, and missing laundry items that were not returned for extended periods. Despite these concerns being brought up consistently from September through December, the problems persisted without resolution. Observations and interviews confirmed that laundry items were often unlabeled, inventory records were incomplete or not updated, and mesh bags intended to help track laundry were not consistently used by nursing staff. Staff interviews further revealed that complaints about insufficient cleaning and missing laundry were common and had been discussed both in Resident Council meetings and through individual grievances. Specific areas, such as the B hall, were noted as not being cleaned frequently, and residents expressed dissatisfaction with the thoroughness of housekeeping. The facility's failure to respond effectively to these repeated concerns resulted in ongoing deficiencies in both laundry and housekeeping services, affecting any resident whose needs in these areas were not met.
Failure to Maintain Clean Environment and Proper Laundry Management
Penalty
Summary
The facility failed to maintain a clean, safe, and homelike environment for residents, as evidenced by persistent cleanliness issues and mismanagement of residents' personal laundry. Observations over several days revealed multiple dried spills, dirt, debris, and bug traps with accumulated dust and insects throughout various hallways and resident rooms. Specific rooms and common areas were noted to have unclean floors, uncollected trash, and visible stains, despite cleaning logs indicating recent cleaning. Residents and staff reported ongoing complaints about inadequate housekeeping, with grievances and Resident Council minutes documenting repeated concerns about insufficient cleaning, especially in resident rooms, bathrooms, and dining areas. Laundry management was also deficient, with staff interviews and observations indicating that residents' clothing was frequently unlabeled, leading to confusion and loss of personal items. Laundry staff described a process where unmarked clothing was hung on racks in hallways, as they were unable to identify the owners. Missing item forms and grievance forms were often completed when residents reported lost clothing, but inventories were not consistently updated when new items were brought in. This resulted in a significant accumulation of unclaimed clothing and limited storage space. Staff also noted that families sometimes resisted labeling clothing, further complicating the process. These deficiencies culminated in an altercation between two residents when one resident recognized his clothing being worn by another. The clothing in question had been relabeled with the second resident's name after the original label was crossed out. Facility records showed multiple grievances related to missing clothing and laundry delays, as well as complaints about room and facility cleanliness. Staff interviews confirmed that these issues were ongoing and had been raised repeatedly by residents and staff alike.
Failure to Timely Report Abuse Allegations and Investigation Results
Penalty
Summary
The facility failed to report allegations and findings of abuse in a timely manner to the State Survey Agency for three sampled residents. In one instance, an alleged incident of physical abuse involving two staff members and a resident occurred, but the event was not reported within the required two-hour timeframe, and the final findings were not submitted within the required five working days. Staff attributed the delay to technical issues with the abuse reporting system. In another case, a verbal altercation between two residents was not reported until two days after the event, as it was only discovered during a chart review. The nurse involved did not report the incident immediately, resulting in late notification. The facility's policy requires immediate reporting of abuse allegations, but these procedures were not followed in the cited incidents.
Failure to Develop Person-Centered Care Plan and Provide Individualized Dementia Interventions
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with dementia who exhibited aggressive behaviors, wandering, frequent falls, pain, and was at risk for elopement. The care plan lacked specific dementia-related interventions and relied primarily on nonspecific redirection strategies. Staff interviews revealed that key team members were unaware of the full extent of the resident's behaviors, such as constant wandering, and therefore did not include appropriate interventions in the care plan. The care plan did not provide measurable or detailed actions for staff to follow, and interventions were often generic or unrealistic given the resident's cognitive status. Record reviews showed that the care plan did not address the resident's pain management needs, as interventions for pain in the right knee were missing, and pain goals were not individualized or specific to the resident's condition. The plan for cognitive decline included unrealistic goals, such as developing coping skills, despite severe cognitive impairment. Interventions for falls, elopement, and aggressive behaviors were vague, lacked specificity, and did not reflect the resident's actual patterns or needs. For example, the falls care plan did not address the resident's weakness, confusion, or poor safety awareness, and did not specify which items should be kept within reach or how to anticipate the resident's needs. Additionally, the facility failed to provide meaningful activities for residents in the memory care unit, as reported by both family and staff interviews. The care plan for elopement risk referenced offering preferred activities, but none were listed, and interventions were generic and not tailored to the resident. The lack of individualized, person-centered interventions and activities resulted in staff lacking clear guidance to effectively meet the resident's needs, leading to inconsistent and potentially unsafe care, as well as unmet psychosocial needs for multiple residents.
Failure to Provide Individualized Activities for Dementia Residents in Memory Care Unit
Penalty
Summary
The facility failed to provide an ongoing program of daily, individualized or group activities and meaningful engagement for residents with dementia residing on the secure memory care unit. Observations revealed that several residents were sitting in the common room without any music, television, or interactive activities occurring. Multiple interviews with family members and staff confirmed that there were no consistent activities provided for residents in the secure unit, with staff noting a lack of time and resources to conduct such activities. Family members reported never witnessing activities during their visits, and staff expressed concern about the absence of daily engagement, which they identified as important for redirecting and ensuring the safety of dementia residents. Documentation regarding activity participation for three sampled residents in the secure memory care unit was requested but not provided by the facility. Review of facility policies indicated that special considerations should be made for developing meaningful activities for residents with dementia and that appropriate treatment and services should be provided to meet their highest practicable well-being. Despite these policies, the facility did not demonstrate that activities were planned or implemented for residents in the secure memory care unit, leading to a deficiency in meeting their cognitive and psychosocial needs.
Failure to Accurately Assess and Document Resident Wandering Behaviors
Penalty
Summary
The facility failed to accurately identify and document wandering behaviors on the MDS Resident Assessments for one resident with dementia and a known history of daily wandering. Staff responsible for completing the admission MDS assessment did not review the resident's medical diagnoses or fully consider behaviors prior to admission, instead assuming the assessment only pertained to current behaviors observed within the facility. The staff member also did not interview the resident or family members, relying solely on progress notes, which resulted in the omission of the resident's daily wandering behavior from the assessment. The resident's electronic health record indicated a diagnosis of wandering at admission and contained multiple progress notes documenting daily incidents of wandering and exit-seeking from the day of admission onward. Despite this, the admission MDS assessment indicated no wandering behaviors, and the subsequent quarterly MDS assessment understated the frequency of wandering. This inaccurate documentation limited the facility's ability to implement appropriate care plan interventions to address the resident's actual care needs.
Inadequate Staffing Leads to Delayed Call Light Response and Pain Management
Penalty
Summary
The facility failed to ensure timely response to residents' call lights, leading to inadequate pain management and feelings of insecurity among residents. Multiple residents reported waiting over 30 minutes for their call lights to be answered, particularly during night shifts. One resident mentioned waiting over an hour for assistance, while another expressed concerns about the facility being understaffed, especially at night, with only two CNAs available for over 60 residents. Staff interviews corroborated these concerns, with reports of insufficient staffing due to budget constraints, leading to delays in addressing residents' needs. Additionally, residents experienced delays in receiving pain medication, with one resident waiting over an hour for Tylenol to manage hip pain. Another resident, with a history of spondylosis, arthropathic psoriasis, and other conditions, reported daily pain and inadequate repositioning assistance. Staff members acknowledged the staffing issues, noting that nurses were often overburdened with responsibilities, including administering medications and conducting assessments, without adequate support. The facility's call light audit indicated a goal of a 5-minute response time, which was not being met, contributing to resident dissatisfaction.
Infection Control and Documentation Deficiencies
Penalty
Summary
The facility failed to ensure proper implementation of transmission-based precautions, documentation, and notification of COVID-19 tracing, and lacked a system to prevent and monitor waterborne illnesses. Observations revealed that staff members did not adhere to contact precautions, as they entered rooms of residents under such precautions without wearing personal protective equipment (PPE). Specifically, staff members were seen in a resident's room without PPE despite the resident being on contact precautions for shingles. Additionally, there was confusion among staff regarding which residents required contact precautions, leading to incorrect signage on room doors. The facility also failed to document COVID-19 testing for residents who were close contacts of a staff member who tested positive. Although testing was conducted, progress notes for several residents did not reflect the testing or results. Furthermore, a resident who was a close contact was placed on oxygen due to low saturation levels, but staff were unaware of the resident's status in the COVID-19 testing protocol. Lastly, the facility lacked procedures or systems to address waterborne microorganisms, as confirmed by a staff member, despite having a policy that required such measures.
Deficiencies in Cleanliness and Personal Item Management
Penalty
Summary
The facility failed to maintain a clean and safe environment in the resident shower areas and did not adequately safeguard residents' personal belongings from loss or theft. Observations revealed that the shower rooms, particularly outside the memory care unit, were not properly cleaned, with used washcloths, pooled dirt, and malodorous smells present. Additionally, there were brown stains near the drain and a dirty brief on the floor, indicating a lack of proper sanitation and infection control measures. The facility also failed to exercise reasonable care in managing residents' clothing and personal items, leading to frequent reports of missing belongings. Several residents and staff members reported missing clothes and personal items, such as an iPad and an Apple Watch, which were not adequately addressed through the facility's grievance process. The facility's system for tracking and returning lost items was ineffective, with staff spending significant time searching for missing items and a lack of a clear policy or procedure for handling such issues. Interviews with staff revealed that the facility's inventory process for residents' personal belongings was insufficient, with only a small portion of the staff having received training on completing inventory listings. The facility's failure to provide a comprehensive and effective system for managing residents' personal items and maintaining a clean environment contributed to the deficiencies identified during the survey.
Deficient Grievance Program for Lost Resident Belongings
Penalty
Summary
The facility failed to maintain an effective grievance program to address resident concerns, particularly regarding lost belongings. Observations and interviews revealed that grievances related to missing items were not consistently elevated to a formal grievance level by management. Staff member C, identified as the grievance officer, indicated that the administrator and director of nursing were responsible for determining which issues were considered grievances. Staff member A noted that the grievance log for August 2024 was missing and acknowledged that not all concerns were documented as grievances, sometimes resulting in incomplete records. Resident #67, who had recently been discharged, was still missing personal items, including an iPad, an Apple Watch, and clothing, which were documented in the resident's personal belonging inventory. Despite these items being inventoried, a grievance was not resolved for the lost belongings. The report highlights that grievances were not being addressed effectively, as evidenced by the grievance report forms dated 3/1/24, which expressed dissatisfaction with the grievance process. This deficiency increased the risk of negative outcomes for residents with unresolved grievances or lost items.
Deficiencies in Pain Management for Residents
Penalty
Summary
The facility failed to ensure proper pain management for several residents, leading to deficiencies in care. Resident #14, who has advanced dementia, was observed to be in distress and exhibiting behaviors indicative of pain, such as grimacing and rocking. Despite these signs, the resident's medication administration reports showed no scheduled pain medication, only PRN orders, and there were numerous missed opportunities for pain assessments. The resident's care plan and progress notes indicated behaviors consistent with pain, yet there was a lack of consistent pain management interventions. Resident #29 reported frequent pain in her left hip and experienced delays in receiving pain medication, affecting her ability to move and increasing the risk of skin breakdown. Despite a physician's order for palliative care, the facility did not have such services, and staff were unclear about the order's implementation. This lack of clarity and delay in pain management contributed to the resident's discomfort and potential health risks. Resident #10 also reported unmanaged pain and a lack of regular pain assessments, with several missed assessments documented in the electronic health record. The resident's diagnoses included conditions that could cause significant pain, yet the facility failed to document pain progress notes when pain levels were reported at 5/10 or higher. Similarly, resident #30 was unfamiliar with the pain scale and had several missed pain assessments, with most assessments inaccurately recorded as 0/10. The facility's failure to provide a pain management policy further highlights the systemic issues in addressing residents' pain needs.
Failure to Follow Up on Dental Care Referrals
Penalty
Summary
The facility failed to follow up on dental care referrals for several residents, leading to unresolved dental issues. Resident #5 had been seen by a dental hygienist who identified multiple dental concerns, including possible decay, broken teeth, and root tips. Despite a physician's order for a dental referral dated April 15, 2024, there was no evidence of follow-up or treatment for these issues in the resident's electronic health record (EHR) as of January 13, 2025. Staff member B acknowledged the referral was received in May 2024 but was not acted upon. Additionally, residents #48, #3, #6, and #280 experienced issues with ill-fitting dentures, impacting their ability to eat properly. Resident #48 reported difficulty eating certain foods due to poorly fitting dentures and experienced a significant weight loss of 6.15% over two months. Residents #3 and #6 also reported problems with their dentures slipping or not fitting, leading to difficulties in eating. Resident #280 was observed leaving food on his plate due to his dentures not fitting well, which he stated affected his ability to consume enough protein for his renal diet. No documentation of dental notes or appointments for these residents was provided by the end of the survey.
Delayed and Unappetizing Meals Served to Residents
Penalty
Summary
The facility's dietary department and staff failed to serve meals in a timely manner, resulting in cold food being served to residents. Observations and interviews revealed that breakfast was consistently served late, with some residents reporting delays of up to an hour. For instance, a resident in the dining room noted that breakfast was typically 30 minutes late, while another resident in the E wing reported receiving cold eggs when her tray was delivered. Additionally, lunch was also served late, as evidenced by a resident in the A wing who frequently received cold meals. Furthermore, several residents expressed dissatisfaction with the quality of the food. One resident relied on family members to bring in meals due to disliking the facility's food. Another resident found her oatmeal too thick and was not provided with the lactose-free milk indicated on her meal ticket. Additionally, a resident was observed picking out burnt pieces from her eggs, expressing displeasure with the food quality. Staff members corroborated these complaints, with one describing the food as "disgusting" and another stating that residents compared it to "jail food."
Inadequate Supervision and Positioning in LTC Facility
Penalty
Summary
The facility failed to provide adequate staff supervision on the memory care unit, affecting three residents. Staff members reported that the unit had a high number of residents with behavioral issues, yet staffing levels were insufficient, with only three staff in the mornings and two in the afternoons. This lack of supervision was evident when a surveyor had to intervene in a confrontation between two residents, as no staff were present to manage the situation. Additionally, a resident was observed walking barefoot with an unstable gait and holding a fork, posing a risk of injury, while staff were occupied elsewhere. The facility also failed to implement effective interventions for a resident who eloped. Staff expressed concerns about the inefficiency of the wanderguard system, noting that some doors did not lock when a wanderguard was near, allowing the resident to exit the facility. The transitional care unit, where the resident resided, was unsupervised and had multiple exit points, further contributing to the elopement risk. Furthermore, the facility did not ensure proper positioning for two residents during meals, increasing the risk of choking. One resident was observed coughing and struggling to swallow while slouched in a chair, contrary to dietary orders requiring an upright position. Another resident was left in a flat position with a kinked neck while eating, which staff acknowledged could be a choking hazard. These observations highlight the facility's failure to adhere to care plans and dietary orders, compromising resident safety during meals.
Failure to Refer Resident for PASARR Level II Assessment
Penalty
Summary
The facility failed to refer a resident for a PASARR Level II assessment after a diagnosis of Post Traumatic Stress Disorder (PTSD) was added. The resident, who had a history of serving in the special forces during the Korean and Vietnam wars and was a prisoner of war, had a PASARR Level I assessment dated 6/21/24 that did not include the PTSD diagnosis. The resident's Minimum Data Set (MDS) dated 6/27/24 also did not reflect the PTSD diagnosis, but a subsequent MDS dated 9/22/24 did include it. During an interview, a staff member acknowledged that a new PASARR Level I should have been completed when the PTSD diagnosis was added to determine if a Level II assessment was necessary. However, no Level II request was made before the survey concluded.
Failure to Document Enteral Feeding in Baseline Care Plan
Penalty
Summary
The facility failed to include critical information on a resident's baseline care plan regarding their need for enteral tube feedings. This oversight was identified for one of the sampled residents who had a history of spinal cord injury, Parkinson's disease, and aspiration pneumonia, and was designated as NPO (nothing by mouth) due to the risk of aspiration. Despite the resident's medical history and specific provider orders for continuous tube feeding with Isosource 1.5 at 70 ml/hr and free water flushes, the baseline care plan did not reflect these essential care requirements. During an interview, a staff member indicated that the admitting nurse is responsible for initiating the baseline care plan for new admissions, and if incomplete, the floor nurse should finalize it. However, the care plan for this resident failed to document the need for enteral feeding, which was acknowledged as a necessary inclusion by the staff. The facility's policy mandates a comprehensive, person-centered care plan to address each resident's needs, but this was not adhered to in this instance, increasing the risk of improper care.
Failure to Assist Residents with ADLs
Penalty
Summary
The facility failed to provide necessary assistance to a resident during meals. Observations revealed that a staff member was the only one available to pass medications and food trays, which led to a situation where a resident, who was marked as dependent on their MDS for eating, was left attempting to feed himself without assistance. On multiple occasions, the resident was observed struggling to eat and drink without staff assistance or cueing, despite the care plan indicating the need for extensive assistance by one staff member. Another deficiency was noted in the facility's failure to assist a resident with toileting and dressing. The resident, who has Parkinson's disease, expressed that her ability to use the bathroom fluctuates and that she needed assistance. Despite this, she was found struggling to dress herself after using the bathroom, visibly upset and crying, with her call light on. The care plan indicated that she required supervision for toileting and setup assistance for dressing, but these needs were not met, as evidenced by the resident's struggle and the lack of staff assistance.
Delayed Hospice Referrals and Care Plan Confusion
Penalty
Summary
The facility failed to ensure timely hospice referrals for two residents, leading to significant delays in care. For one resident, an order for a hospice referral was received due to weight loss and senile degeneration of the brain, but the referral was not completed until eleven days later. This delay was compounded by a significant fall that resulted in an emergency room visit. Despite the resident's power of attorney expressing a desire to start hospice, the process was delayed by a month. Staff interviews revealed that the facility struggled with managing lab results, new orders, and referrals due to staffing issues, and hospice admissions were reportedly delayed by two weeks. Another resident experienced severe pain post-CVA and had a physician's order for hospice referral, but there was confusion regarding the implementation of palliative care. The resident reported significant pain and delays in receiving pain medication, and there was concern about skin breakdown due to immobility. Despite a physician's order for palliative care, staff indicated that the facility did not have a palliative care policy, leading to further confusion and inaction. The lack of communication and clarity regarding the resident's care plan contributed to ongoing pain management issues.
Failure to Provide PTSD Treatment for Veteran Resident
Penalty
Summary
The facility failed to provide necessary treatment and services for a resident diagnosed with post-traumatic stress disorder (PTSD). The resident, a veteran who experienced combat in Korea and Vietnam and was a prisoner of war, expressed the need for psychiatric or counseling services for PTSD. Despite having a medical diagnosis of PTSD, the resident had not been referred for appropriate treatment. Staff confirmed that no referral had been made, and no documentation was provided to show that a referral for PTSD treatment had been initiated by the facility.
Failure to Follow Posted Menus
Penalty
Summary
The facility failed to adhere to the posted menu for two out of three observed meals, which could potentially affect any resident relying on the posted menu. During observations on January 14, 2025, at 8:33 a.m., 8:37 a.m., and 8:41 a.m., whole grain toast was not present on a resident's plate, despite being listed on the breakfast menu for that day. Additionally, on January 15, 2025, at 12:37 p.m., the lunch served included potato soup, ham and cheese on a croissant, watermelon, and a cupcake, which did not match the posted lunch menu that listed garden vegetable soup, classic beef stroganoff, lemon buttered broccoli, a baked roll, and raspberry jello salad. These discrepancies indicate a failure to follow the planned and posted menus, which are intended to meet the nutritional needs of the residents.
Failure to Follow Physician-Ordered Therapeutic Diets
Penalty
Summary
The facility failed to ensure that physician-ordered therapeutic diets were followed for three residents. Resident #12, who was on a consistent carbohydrate (CCHO) diet, reported that the meals provided were not suitable for her diabetic condition, as they contained too many carbohydrates. She mentioned that her blood sugar levels were often high since her admission, and she had to bring her own food. Resident #48, also on a CCHO diet, had to remind staff to provide sugar-free syrup, as they would often serve regular syrup with her breakfast. Staff member F confirmed that therapeutic diets, particularly for dialysis and diabetic residents, were not being followed due to budget constraints. Resident #280, who had end-stage renal disease and required a renal diet, expressed difficulty in consuming enough protein due to ill-fitting dentures, which made it hard to chew meats. Despite his condition, his electronic health record indicated a regular diet with soft and bite-sized textures, rather than a renal diet. Staff member J noted that diabetic residents were receiving the same diet as others without dietary restrictions, and there were no sugar-free snack options available. Staff member L was unaware of the renal diet and misunderstood the requirements of a carbohydrate diet. The facility's document on therapeutic diets stated that snacks should be compatible with the therapeutic diet, which was not being adhered to in practice.
Medication Administration Error
Penalty
Summary
Facility nursing staff failed to administer two medications during the evening medication administration time for a resident, resulting in a 6.4 percent medication error rate. The medications involved were Cefdinir, an antibiotic prescribed to be taken twice daily for pneumonia, and Potassium Chloride, prescribed twice daily for encephalopathy. The resident's electronic health record (EHR) showed physician orders for these medications, but the medication administration record (MAR) did not document them as given during the scheduled medication pass. Interviews with staff members confirmed that if a medication is not marked off in the MAR as given, it is considered a medication error. The facility's policy on administering medications, revised in December 2012, requires that medications be administered safely, timely, and as prescribed, with documentation in the MAR after each administration. The failure to document the administration of these medications as per the policy led to the identified deficiency.
Significant Medication Error Due to Non-compliance with Medication Administration Procedures
Penalty
Summary
The facility experienced a significant medication error involving a resident who was given incorrect medications by a staff member. The staff member, while administering medications, pre-poured medications for two residents to save time, which is against the facility's policy. During this process, the staff member mistakenly gave a resident a 10 mg Vicodin and 60 mg OxyContin, both high-dose opioids, instead of the requested Tylenol. This error occurred because the staff member did not adhere to the facility's medication administration procedures, which require verifying the resident's identity and checking the medication label three times. Following the medication error, the staff member failed to implement appropriate health monitoring for the resident. The staff member did not take baseline vital signs, did not monitor the resident's oxygen saturation continuously, and did not look up the side effects of the medications administered. Approximately two hours after the error, the resident was found unresponsive with low blood pressure and low oxygen saturation. Narcan was administered to reverse the effects of the opioids, and the resident was sent to the hospital. The resident's medical records showed a lack of documentation of vital signs or consciousness state between the time of the medication error and the hospital transfer. The hospital records indicated that the resident was treated for an opioid overdose and developed aspiration pneumonia. The facility's policies clearly outlined the procedures for medication administration and monitoring after a medication error, which were not followed by the staff member involved.
Significant Medication Errors in LTC Facility
Penalty
Summary
The facility failed to prevent significant medication errors for two residents, resulting in an Immediate Jeopardy level deficiency for one resident. A staff member mistakenly administered a high dose of opioid medications, Vicodin and OxyContin, to a resident who requested Tylenol. The staff member pre-poured medications for efficiency, which led to the error. After realizing the mistake, the staff member contacted the on-call provider but did not take immediate vital signs or monitor the resident's oxygen saturation. The resident was later found unresponsive with low blood pressure and oxygen saturation, requiring emergency medical intervention and hospitalization for an opioid overdose. Another resident received an incorrect dosage of Trospium due to a transcription error in the electronic medical record. The order was entered incorrectly as 60 mg four times a day instead of the intended 60 mg once daily. This error went unnoticed for several days until the pharmacy identified the mistake. The resident received double the recommended dose for a week, although no adverse effects were reported. The facility's policies on medication administration and error monitoring were not followed, contributing to these errors. The staff failed to verify the resident's identity and medication details adequately, and the double-check system for entering medication orders was not effectively implemented. These lapses in protocol led to significant medication errors, posing serious risks to the residents' health and safety.
Medication Error and Inadequate Resident Protection
Penalty
Summary
The facility failed to protect a resident from neglect of medical care when a licensed staff member administered incorrect medications, resulting in a significant medication error. The staff member gave the resident 10 mg of Vicodin and 60 mg of OxyContin, which were not prescribed for the resident. Following the error, the staff member did not take baseline vital signs or place the resident on continuous oxygen saturation monitoring. Approximately two hours later, the resident was found hypotensive, with low oxygen saturation levels, and unresponsive. Narcan was administered to reverse the effects of the opioids, and the resident was sent to the emergency room, where they were treated for an opioid overdose and aspiration pneumonia. The facility also failed to protect two residents in the memory care unit from engaging in sexual contact without prior assessment of their ability to consent. Staff members found the two residents naked in bed together, but there was no documentation of an assessment to determine their capacity to consent to sexual activity. Both residents had cognitive impairments, with one having a diagnosis of unspecified dementia and the other having a diagnosis of Frontotemporal Neurocognitive Disorder and unspecified dementia. The facility's policy required an evaluation of the residents' capacity to consent, which was not conducted. Additionally, the facility failed to protect a resident from a resident-to-resident abuse event that resulted in a fall. A resident with a history of wandering entered another resident's room, leading to a confrontation where the second resident pushed the first, causing them to fall. The facility's policy on abuse prevention was not adequately enforced, as the staff was aware of the wandering behavior but did not prevent the incident. The resident who fell had diagnoses of repeated falls, muscle weakness, altered mental status, Alzheimer's disease, and dementia.
Failure to Prevent Falls and Ensure Resident Safety
Penalty
Summary
The facility failed to protect two residents from accidents and hazards, leading to multiple falls and injuries. Resident #9 experienced eight falls within 17 days, resulting in significant injuries, including a traumatic subarachnoid hemorrhage and compression fractures. Despite being identified as a high fall risk, interventions were not effectively implemented or communicated among staff. Staff member F admitted to not knowing how to access or update care plans, and there was a lack of staff signatures on a document outlining interventions for Resident #9. Resident #10, who has a history of wandering due to Alzheimer's and dementia, was pushed by another resident, resulting in a fall. The incident occurred in a memory care unit where residents frequently wander into each other's rooms. Staff member K acknowledged the difficulty in preventing such incidents, and staff member F used Google Translate to communicate with Resident #10, who only speaks Russian. The care plan for Resident #10 included wearing appropriate footwear and redirecting her from other residents' rooms, but these measures were not effectively enforced. The facility's documentation and communication regarding fall risks and interventions were inadequate. Staff members were not fully aware of care plan updates, and incidents were not consistently logged. Resident #9's falls were not included in the fall log because she had been discharged, indicating a lack of comprehensive tracking and follow-up on fall incidents. These deficiencies highlight a failure in ensuring a safe environment and adequate supervision for residents at risk of falls.
Failure to Report Neglect and Inappropriate Sexual Contact
Penalty
Summary
The facility failed to identify and report an incident of suspected medical neglect involving a resident who was given the wrong medications by a staff member. The staff member administered 10 mg of Vicodin and 60 mg of OxyContin by mistake, and although the provider was notified, the resident was not placed on a continuous oxygen saturation monitor nor were vital signs taken immediately. The resident was found unresponsive three hours later, requiring Narcan and emergency medical intervention. The facility's administrator and another staff member did not recognize the incident as neglect and failed to report it to the State Survey Agency. Additionally, the facility did not report an incident of inappropriate sexual contact between two residents to the State Survey Agency. One staff member found the residents naked in bed together but did not assess their capacity to consent to sexual behavior, assuming the interaction was consensual. Both residents had diagnoses that could impair their ability to consent, including unspecified dementia and Frontotemporal Neurocognitive Disorder, yet their electronic medical records lacked assessments of their ability to consent and documentation of the incident. The facility's policy on abuse prevention outlines the need to report incidents of neglect and nonconsensual sexual contact, but these incidents were not reported as required. The State Survey Agency's reporting system showed no record of the incidents being reported, indicating a failure in the facility's adherence to its own policies and regulatory requirements.
Failure to Investigate Medication Error and Assess Consent in Sexual Contact
Penalty
Summary
The facility failed to fully investigate a significant medication error involving a resident who was given incorrect medications, resulting in the resident becoming unconscious and hypoxic. A staff member accidentally administered 10 mg Vicodin and 60 mg OxyContin to a resident who did not have these medications prescribed. The staff member administered Narcan and called 911, but there was a lack of documented vital signs monitoring between the time of the error and the resident's transfer to the hospital. The investigation into the incident was inadequate, lacking input from the QAPI committee, medical director, and consultant pharmacist. Additionally, there was no evidence of education or policy review for other nurses following the incident. The facility also failed to investigate an incident involving sexual contact between two residents who were not assessed for their capacity to consent. A staff member found two residents naked in bed together, but no assessment was conducted to determine if the contact was consensual. Another resident reported inappropriate sexual comments from one of the involved residents, leading to her isolation in her room. The facility did not provide documentation of any investigation or capacity assessments prior to the incident, and assessments were only completed after the surveyor's request. The facility's policy on abuse prevention requires an evaluation of a resident's capacity to consent to sexual activity if there is any suspicion of incapacity. However, this policy was not followed, as no assessments were conducted before the incident. The lack of investigation and assessment allowed ongoing inappropriate behaviors to go unaddressed, affecting the well-being of other residents.
Facility Fails to Maintain Clean Environment for Residents
Penalty
Summary
The facility failed to maintain a clean and safe environment for its residents, as evidenced by observations and interviews conducted during a survey. Twelve out of fourteen sampled residents had rooms that were not cleaned regularly, with issues such as dried food particles, dust, and sticky substances on the floors, as well as dried feces and urine on toilet seats. Residents reported that housekeeping services were infrequent, with some rooms being cleaned only once a week or less. The lack of cleanliness extended to common areas, with hallways also noted to have sticky substances and dirt. Interviews with staff revealed that the facility was understaffed in housekeeping, with only one housekeeper present at times and no replacements available when staff called off. The housekeeping supervisor acknowledged the complaints and stated that the best service would involve daily cleaning of residents' rooms. The facility's grievance reports indicated ongoing concerns about housekeeping, with issues such as garbage not being emptied, floors not being swept, and supplies not being refilled. These grievances had been consistently raised by the resident council and individual residents over several months.
Lack of Structured Activities in Memory Care Unit
Penalty
Summary
The facility failed to provide a structured activities program tailored to meet the individual preferences and needs of residents in the secured memory care unit. This deficiency was identified through observations and interviews conducted on June 4, 2024. A resident from the general care unit noted that residents from the memory care unit did not participate in activities outside their unit. Staff interviews revealed inconsistencies in the provision of activities, with some staff members stating that certified nursing assistants (CNAs) engaged residents in activities like coloring, puzzles, and television programming, while others indicated a lack of structured activities and the absence of an activities aide. Observations in the memory care unit showed residents sitting in recliners and at tables with the television on, but no structured activities were taking place. Staff members confirmed the absence of an activities aide since November 2023 and acknowledged the lack of structured activities in the unit. The deficiency was attributed to the absence of a dedicated activities aide and the reliance on CNAs to provide activities, which were not consistently implemented or structured to meet the residents' needs.
Failure to Prime Insulin Pen Before Administration
Penalty
Summary
Staff member M failed to provide services that met professional standards of quality by not priming an insulin pen before administering insulin to a resident. During an observation, staff member M was seen retrieving two new insulin pens for the resident and labeling them with an opening date. However, staff member M did not prime either the Tresiba or Novolog insulin pen with 2 units of insulin to clear any air from the pens before administration. In an interview, staff member M admitted to not knowing about the priming process, as it was her first day at the facility after working at another long-term care facility. The facility's policy clearly states that a 2-unit dose of insulin must be dialed and released as an air shot prior to administering each prescribed dose.
Failure to Provide Necessary Care and Services
Penalty
Summary
The facility failed to provide necessary care and services for a dependent resident, leading to the resident feeling unsafe, dirty, and embarrassed. The resident, who was admitted for rehabilitation to increase strength, experienced a lack of assistance from staff in moving in bed, long wait times for call light responses, and no help with toileting needs. The resident reported wearing the same underwear throughout the stay and not having a bedside commode, which resulted in being told to hold bowel movements. Upon discharge, the resident was admitted to a critical access hospital with open, bleeding sores on the buttocks, indicating a lack of proper care during the stay. Interviews with staff revealed that while the scheduling was consistent, not all residents knew to use their call lights, necessitating regular check-ins by staff. Despite this, the resident reported that staff did not assist with repositioning or transfers, and the urinal was not emptied. The resident's admission records indicated a need for extensive assistance with mobility and personal care, yet these needs were not met, resulting in skin integrity issues and a feeling of mistreatment. The resident's cognitive patterns were intact, and the baseline care plan included interventions for repositioning and peri-care, which were not adequately implemented.
Inadequate Infection Control Practices by Staff Member
Penalty
Summary
Staff member M failed to perform proper hand hygiene and use protective measures during medical procedures for a resident. Observations revealed that staff member M did not sanitize her hands upon entering or exiting the resident's room, nor did she don gloves during blood glucose monitoring, insulin administration, or the administration of eye drops. Additionally, she placed the glucometer and supplies directly on the resident's overbed table without a protective barrier and failed to clean the glucometer after use, which was then stored without disinfection. Interviews with staff members indicated that the facility's policy requires hand hygiene before entering and exiting a resident's room, and the use of gloves during specific procedures. The policy also mandates the use of MicroKill wipes for cleaning glucometers shared among residents. Staff member M admitted to not following these protocols due to being in a rush and was unaware of the proper cleaning method for the glucometer. This oversight had the potential to increase the risk of spreading bloodborne pathogens among residents.
Failure to Maintain Clean Environment
Penalty
Summary
The facility failed to ensure a clean environment for 10 of 14 sampled residents, leading to feelings of discouragement and frustration among residents. Observations revealed soiled diapers left in rooms, dirty floors, and food wrappers under beds. Specific instances included dirt-like clumps on the floor, dried coffee spills in hallways, and multiple dried liquid spots. Interviews with staff members indicated that housekeeping was short-staffed, resulting in rooms going uncleaned for several days, especially on weekends and after 3:30 p.m. Residents reported not seeing their rooms cleaned or bed sheets changed for several days. Resident #3's room had crumbs, debris, a soiled bed pad, and a broken sink handle. The resident's clothes were piled up, and a food tray was left from breakfast. The resident expressed frustration and discouragement, stating that complaints about these issues had not been addressed. The resident's Annual MDS showed a BIMS of 15, indicating cognitive intactness. A grievance report from the resident dated 3/5/24 highlighted concerns about unemptied garbage and unswept floors. The facility's policy on Resident Environmental Quality emphasized maintaining a safe, functional, sanitary, and comfortable environment, which was not upheld in this case.
Failure to Implement Care Planned Fall Interventions
Penalty
Summary
The facility failed to implement care planned fall interventions for a resident identified as being at risk for falls. The resident's care plan included specific interventions such as ensuring adequate lighting, appropriate footwear, the use of a fall mat, and the addition of non-slip strips to the floor. However, during an observation, the resident was found sitting on the floor with no footwear, in a dimly lit room, and without the non-slip strips or fall mat in place. The floor was wet with urine, and the resident's sheets were soaked, indicating a lack of a structured toileting plan. Interviews with staff revealed that the care plan was not followed due to various reasons, including the removal of the fall mat, which was considered a tripping hazard, and a delay in applying the non-slip strips. The staff also indicated that the MDS coordinator was responsible for updating care plans, but there was no clear explanation for the failure to implement the planned interventions. The facility's policy on comprehensive, person-centered care plans was not adhered to, resulting in the resident's increased risk of falls and inadequate care.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement interventions to prevent a fall for a resident with a history of falls and severely impaired cognition. The resident had seven falls within a two-month period, including a fall resulting in a distal clavicle fracture and another fall causing a 4 cm laceration to the scalp. On the day of the incident, the resident was found sitting on the floor, barefoot, in a dimly lit room with wet urine on the floor and soaked bedsheets. The resident was not wearing a brief or bottoms, and the floor lacked non-skid strips or a fall mat. Interviews with staff revealed inconsistencies and failures in implementing the resident's fall prevention interventions. Staff members mentioned that the resident was supposed to wear footwear and have a fall mat by her bed, but these measures were not in place at the time of the fall. Additionally, there was a lack of communication and follow-through regarding the installation of non-skid floor strips, which had been requested but not completed. The resident's care plan included specific interventions to prevent falls, such as ensuring adequate lighting, appropriate clothing, and the use of non-skid slippers, but these were not consistently followed, leading to the resident's fall and injury.
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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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