Libby Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Libby, Montana.
- Location
- 308 E Third St, Libby, Montana 59923
- CMS Provider Number
- 275040
- Inspections on file
- 21
- Latest survey
- July 8, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Libby Care Center during CMS and state inspections, most recent first.
Surveyors identified multiple infection control failures, including improper storage of medications and supplies, unclean medication rooms and refrigerators, and overflowing sharps containers. Staff did not follow proper hand hygiene or PPE protocols during wound and IV care for a resident, and environmental cleaning was lacking, with showers and utility rooms left soiled and supplies stored on floors. Staff interviews confirmed lapses in cleaning and supply management, and residents expressed concerns about cleanliness and wound healing.
The facility did not ensure that advance directives and code status documentation were complete and consistent for three residents. In these cases, POLST forms were either unsigned by a physician, not properly filed in the EHR, or did not match the residents' stated wishes or EHR profiles. Staff acknowledged that unsigned POLSTs were entered into the electronic record before being properly authorized, contrary to policy.
Staff did not consistently document medication refrigerator temperatures as required, with records showing incomplete monitoring for the day shift and no documentation for freezer temperatures during both day and night shifts.
Staff failed to maintain a resident's dignity during peri and wound care by leaving window blinds open, resulting in the resident being exposed to the outside for an extended period. The resident expressed discomfort about being exposed, and staff later acknowledged they should have closed the blinds.
The facility failed to prevent multiple elopements and did not implement an effective system for monitoring residents at risk for elopement. Several residents left the facility unsupervised due to issues such as malfunctioning or unchecked wanderguard bracelets, lack of a comprehensive resident monitoring list, and informal procedures for elopement prevention. Staff relied on inconsistent methods to check safety devices and did not follow recommended practices for tracking and maintaining elopement prevention systems.
Staff did not adhere to a physician's order requiring a resident to wear TED hose at all times following knee surgery. Instead, staff removed the antiembolism stockings at night, referencing a facility policy, even though the facility's own policy did not direct such removal and a physician's order should have taken precedence.
A resident with a history of behavioral health issues experienced a significant mental and physical decline after hospitalization. Despite assessments and a contracted telehealth psychiatrist, the facility's interventions were ineffective, and the resident continued to display multiple disruptive behaviors. The facility documented these behaviors and issued a discharge notice, stating it was unable to manage the resident's addiction and mental health needs.
A resident admitted for rehab after knee surgery, with a history of Parkinson's, received home medications brought in by family due to insurance coverage issues. Facility staff did not verify the contents of these prescription bottles or reconcile a dosage discrepancy between the physician's order and the prescription label for clonazepam. Staff interviews revealed confusion about the process, and the facility's policy prohibiting acceptance of such medications was not followed.
A facility failed to include a resident's history and risk of suicide in the baseline care plan after admission from an overdose. Despite a suicide risk assessment and depression screening, the care plan lacked information on the resident's suicide risk or history, and there were no orders to monitor for suicide risk. Hospice notes indicated a suicide risk due to prior attempts and expressions of isolation.
The facility failed to coordinate care and communication with hospice for two residents, leading to issues with medication management and lack of documentation. Staff were unsure about hospice care plans and medication orders, resulting in inconsistencies in administration. The facility lacked documentation of hospice care plans and visit records, contributing to the deficiency in providing appropriate treatment and care.
Widespread Infection Control Failures in Facility
Penalty
Summary
Multiple infection prevention and control deficiencies were identified throughout the facility. In the medication rooms, supplies and medications were found stacked in corners and on the floor due to inadequate shelving, and countertops were cluttered and soiled, with personal items and debris present. The medication refrigerator contained spilled wine and food, and had not been cleaned, with staff confirming that nursing was responsible for its maintenance but had not done so. Overflowing sharps containers were also observed on the floor, and various rooms, including utility and shower rooms, had uncleanable surfaces, missing or broken flooring, and visible contamination such as feces, mildew, and trash left unremoved. Staff failed to follow proper infection control practices during resident care. One staff member donned gloves before a gown and touched her hair with gloved hands, then continued to gather supplies without changing gloves, contrary to facility policy. During wound and IV care for a resident, the same staff member repeatedly failed to perform adequate hand hygiene, washing hands for less than the required 20 seconds, touching contaminated surfaces, and handling supplies and wounds without proper glove changes or handwashing. The staff member also did not properly secure PPE gowns during care, only tying them near the end of the procedure, and admitted to not following protocol because the gown was inconvenient. Environmental cleaning and supply storage were also deficient. Showers were not cleaned between resident use due to lack of available cleaning supplies, and clean linens and briefs were stored on floors and in sinks. Staff interviews revealed a lack of accountability and communication regarding cleaning responsibilities and supply management. Resident council minutes and resident interviews reflected dissatisfaction with the cleanliness and odors in shower rooms, and concerns about wound healing. Facility policies on hand hygiene and cleaning were not followed, as evidenced by direct observation and staff statements.
Inconsistent and Incomplete Advance Directive Documentation
Penalty
Summary
The facility failed to ensure that advance directives and code status documentation were complete, accurate, and consistent with the residents' wishes and the electronic health record (EHR) for three of twenty sampled residents. In one case, a resident expressed a clear refusal of any tubes for care, including catheters and feeding tubes, yet the EHR listed the resident as full code with full treatment, and the available POLST forms were inconsistent and not properly signed by a physician. One POLST was not on file in the EHR, and no verbal physician order was documented to support the code status. For another resident, the POLST indicated a do not resuscitate status, but the required signature of the patient or decision maker was only documented as a verbal order without a follow-up physician signature. In a third case, the POLST and EHR code status did not match, and the POLST lacked a physician signature, with no verbal physician order found in the EHR. Staff interviews revealed that unsigned POLST forms were entered into the electronic record before being properly signed, contrary to facility policy and POLST instructions, which require patient or legal decision maker signatures and provider follow-up for verbal orders.
Failure to Consistently Record Medication Refrigerator Temperatures
Penalty
Summary
Staff failed to consistently record the temperatures for the medication storage refrigerator in the team one medication storage room. According to staff interviews, refrigerator temperatures were supposed to be monitored and recorded daily at the beginning of each shift. However, review of the facility's Fridge Temperature Log for June 2025 showed that temperature monitoring was only documented for the day shift 16 times over a 29-day period, and there was no documentation for either day or night shift freezer temperatures.
Failure to Maintain Resident Dignity During Peri and Wound Care
Penalty
Summary
Facility staff failed to ensure resident dignity during peri care and wound care for one resident. During the care session, two staff members performed peri and wound care with the resident's bed positioned against a window with the blinds left open. The bed was raised to the height of the windowsill, and the resident's brief was removed, exposing the resident's peri area to the uncovered window while facing the resident garden area for an extended period. The resident's buttocks were also exposed to the window during wound care. The resident verbally expressed discomfort and stated she did not want to be exposed out the window. Staff later acknowledged that the blinds should have been closed but admitted they did not think about it. Facility policy requires staff to treat each resident with dignity and respect.
Failure to Prevent Elopement and Inadequate Elopement Monitoring System
Penalty
Summary
The facility failed to prevent the elopement of three residents who were identified as being at risk for elopement and did not implement an effective elopement prevention and monitoring system for six residents at risk. Multiple incidents occurred where residents left the facility unsupervised, including one resident found wandering outside after being in the courtyard, another found across town by an off-duty staff member, and a third who exited through a window after removing the screen. In one case, a resident's wanderguard bracelet failed to trigger the alarm due to a low battery, and in another, the method of elopement was not identified. Staff interviews revealed inconsistent practices regarding the monitoring and documentation of wanderguard bracelets and elopement risk. Staff relied on residents passing by doors to check if alarms would sound, rather than using the recommended tools or tracking battery expiration dates. There was no comprehensive list of residents with wanderguard bracelets, and staff were not consistently aware of which residents required monitoring. Maintenance checked doors weekly, but there was no formal policy guiding the monitoring of residents at risk for elopement. Documentation review showed that residents with a history of exit-seeking behaviors and elopements were not always monitored according to their care plans, and the facility's procedures for wanderguard use were informal and lacked specificity. The facility's own wanderguard manual recommended tracking battery expiration dates and using checklists for monitoring, but these practices were not followed. The lack of a formal, effective system for monitoring and preventing elopement contributed to multiple incidents where residents left the facility unsupervised.
Failure to Follow Physician Orders for TED Hose Application
Penalty
Summary
Facility staff failed to follow a physician's admission order for a post-operative resident who had undergone a left total knee surgery. The physician's order specified that TED hose should be worn at all times. Upon admission, staff removed the resident's TED hose on the first night, citing a facility policy intended to prevent skin breakdown, and the stockings remained off the following morning. Interviews with staff confirmed the removal was based on facility practice, despite the physician's order, and review of the relevant facility policy did not support the removal of TED hose at night for pressure ulcer prevention.
Failure to Provide Necessary Behavioral Health Services
Penalty
Summary
The facility failed to provide necessary behavioral health services to a resident with significant behavioral needs. Upon admission, the trauma-informed care assessment did not indicate a need for interventions, and the resident had a low PHQ-9 score for depression and a high score on the Brief Interview of Mental Status. However, after a hospitalization and return to the facility, the resident experienced a noticeable mental and physical decline. Despite the facility having a contract with a telehealth psychiatrist and conducting a Significant Change MDS, the interventions suggested by the psychiatrist were not effective. The resident exhibited multiple concerning behaviors, including calling 911, being combative, offering sexual favors, attempting to remove sanitizer dispensers, possessing vape supplies and alcohol, having non-prescribed medications, exit seeking, and laying on the floor. The facility documented behavior monitoring on the Treatment Administration Record (TAR) and issued a 30-day discharge notice, citing an inability to manage the resident's addiction and mental health needs. The resident had no involved family, POA, or guardian, and the previous treatment center would not accept her back. The resident was scheduled for discharge to her son but was hospitalized and passed away before the discharge could occur. The facility did not provide behavioral health services sufficient to meet the resident's needs during this period of decline.
Failure to Verify and Reconcile Home Medications Brought by Family
Penalty
Summary
The facility failed to implement a process to verify the contents of personal prescription medication bottles brought from home before dispensing them to a resident. A resident admitted for acute rehabilitation following knee surgery, with additional diagnoses including Parkinson's disease, was provided with both new and home medications. The family supplied several of the resident's home medications due to insurance limitations, and these medications were brought in their original prescription bottles. However, there was a discrepancy between the physician's order for clonazepam (2 mg at bedtime) and the prescription label on the bottle (1 mg at night), which was not clarified by nursing staff before administration. Interviews with staff revealed inconsistent understanding and application of the facility's policy regarding the acceptance and verification of medications brought from home. Some staff were unaware of the process for medication reconciliation, and the pharmacy did not examine the pills in the bottles provided by the family. The facility's written policy stated that medications from residents or families should not be accepted due to the inability to reconcile them with prescriber orders, yet this policy was not followed in practice for this resident.
Failure to Address Suicide Risk in Resident Care Plan
Penalty
Summary
The facility failed to include a resident's history and risk of suicide in the baseline care plan for a resident who was admitted post-hospitalization from an overdose. During interviews, staff members revealed that there were no care plans or orders to monitor for suicide risk for the resident. Although a suicide risk assessment and depression screening were conducted upon admission, and it was determined that suicide was not a current issue, the resident's hospice visit notes indicated a suicide risk due to prior attempts and expressions of not wanting contact with others. The facility's care plan, initiated shortly after admission, lacked information on the resident's suicide risk or history of attempts, as well as guidance on how to identify, monitor, or support the resident if signs of risk occurred.
Failure to Coordinate Care and Communication with Hospice
Penalty
Summary
The facility failed to coordinate care and communication with hospice for two residents receiving hospice services. During interviews, staff members revealed that hospice had its own documentation and care plans, which were not shared with the facility. Hospice staff did not attend facility care conferences, and there was no designated facility staff member to coordinate with hospice. This lack of communication led to confusion among facility staff regarding medication orders and care plans for the residents. Observations and interviews highlighted issues with medication management for the residents. Staff were unsure about the hospice care plans and did not have access to hospice visit notes. Medications were provided in bottles with outdated labels, leading to inconsistencies in administration. For instance, a staff member was unsure about the correct dosage of Ativan to administer, as the medication label did not match the new physician orders. Additionally, there were multiple PRN orders for opioids without specific guidelines on when to use each dose, further complicating medication administration. The facility's records lacked documentation of hospice care plans, visit records, and standard hospice contact information until requested by surveyors. Hospice visit records indicated that one resident was considered a suicide risk, but this was not reflected in the facility's care plan. The facility was responsible for coordinating care with hospice, but there was no documentation of a designated staff member for this role. The lack of communication and documentation between the facility and hospice contributed to the deficiency in providing appropriate treatment and care according to orders and residents' preferences and goals.
Latest citations in Montana
A dependent resident admitted post-surgery with intact but vulnerable skin and MASD risk developed significant bilateral buttock MASD and a sacral pressure injury that progressed from deep tissue injury to Stage III and then to a large unstageable ulcer with odor and purulent drainage. Facility records showed incomplete and missing weekly skin/wound assessments during the period when the wound worsened, despite a care plan calling for skin evaluations, turning/repositioning, CNA skin inspections, and monitoring of nutrition. Staff interviews revealed they were frustrated by the resident’s anxiety and behaviors, reported the sacral wound as facility-acquired, acknowledged the resident became obtunded on an intense opioid regimen, and stated they were unaware of excessive fluid intake and could not explain why the worsening wound and infection were not recognized or reported before the resident required hospital transfer for a severe sacral decubitus ulcer with associated infection.
Surveyors found that kitchen staff failed to properly label and date multiple food items stored in the walk-in cooler, including slimy sliced tomatoes, ground meat, sliced ham, roast beef, cheese, and strawberries. Staff reported that they sometimes picked moldy strawberries out of shipments and that moldy dinner rolls had been served and then collected from residents. These practices did not follow the facility’s written policy requiring labeling, dating, and monitoring of refrigerated foods so they are used by their use-by date or discarded, placing all residents at risk for foodborne illness.
The facility failed to submit required investigation findings to the State Survey Agency (SSA) within 5 working days for multiple abuse and elopement incidents. In one case, a resident kicked another resident’s feet, and in another, one resident kicked another in the legs while both were in wheelchairs; in both situations, the facility did not provide timely or, in one case, any investigative findings to the SSA. The facility also reported two separate elopement events for a resident but did not submit final investigation reports for either incident. A staff member reported that another staff member, who was absent during the survey, was responsible for SSA reporting, and confirmed the expectation to report all investigation results within 5 working days per facility policy.
Two residents were involved in a resident-to-resident abuse incident in which one resident kicked another multiple times while both were in wheelchairs, and although staff separated them and documented the event, the facility did not complete or document a formal abuse investigation, did not ensure ongoing protection from further confrontations, and did not report investigative findings to the SSA. In addition, several residents experienced multiple elopements, with documentation that one resident followed others out back doors and another exited through doors into a hospital area, yet the facility’s investigation files lacked clear timelines, comprehensive staff interviews, identification of information sources, and root-cause analyses of exit-seeking behavior. Staff interviews confirmed that while nurses submitted occurrence reports and SSA notifications and discussed root causes informally, management did not consistently document thorough investigations or root-cause findings as required by facility policy.
The facility failed to provide adequate supervision and effective elopement-prevention interventions for several cognitively impaired, exit-seeking residents who were known elopement risks. Despite assessments, care plans, anti-wandering devices, and door alarms, residents repeatedly exited through front and back doors without timely staff redirection or alarm response, and some elopements were not properly documented in the EHR. One resident with dementia and short-term memory loss was not care planned for elopement until after multiple attempts, and another resident with severe cognitive impairment left through sliding doors unnoticed. A resident with an anti-elopement alarm on her wheelchair repeatedly triggered the door alarm throughout the day, yet staff did not effectively respond, allowing her to exit unsupervised and fall on stairs, sustaining minor injuries.
The facility failed to provide meaningful, resident-centered activities for multiple dementia residents in the memory care unit, resulting in individuals sitting idle in dining and common areas, staring at blank or inappropriate televisions, sleeping in chairs, or wandering hallways without engagement. Activity sessions were canceled or not implemented as scheduled, and when paper activities like word searches were offered, only a few residents participated while others received no assistance, including a resident who repeatedly requested glasses and another who did not speak English. Sitters did not help residents with activities, and an activity staff member spent time on a computer and left the unit for other duties. Staff interviews revealed that management directed the limitation of music and physical activities, that residents were often left in bed because it was easier for staff, that floor staff did not conduct activities in the absence of the activity staff, and that the posted activity calendar, which included exercise, trivia, book club, and weekend "Resident Choice Day," was frequently not followed despite a policy requiring meaningful activities tailored to dementia residents.
A hospice resident with metastatic cancer and behavioral symptoms received multiple sedating medications, including quetiapine, hydrocodone, morphine, lorazepam, olanzapine, and prednisone, without thorough assessment for unnecessary drugs, duplicate therapy, or adverse consequences. Despite documented behavioral issues, falls, cognitive decline, and moderate to severe pain scores, staff reported no concerns with the medication regimen. The resident became increasingly sedated, was found unconscious with minimal response to painful stimuli, and was sent to the hospital, where documentation linked the clinical picture to disease progression and medication effects, including opioid use and possible steroid-induced psychosis.
A resident with a documented history of opioid-induced constipation and prior fecal impaction was admitted from the hospital, where providers had noted difficulty balancing opioid use and constipation medications. On admission, facility documentation characterized the resident as having normal stool and rarely needing laxatives. Over the following weeks, bowel records showed multiple days without a bowel movement, yet the MAR reflected no scheduled or PRN constipation medications given. Nursing notes documented no constipation despite absent bowel sounds, while subsequent hospital imaging revealed an extensive rectal stool burden concerning for stercoral colitis. Staff interviews confirmed that the prolonged absence of bowel movements was not reported, the resident received no PRN bowel medications, and there was no specific bowel and bladder management policy.
Staff failed to follow hand hygiene practices while caring for a resident with weeping, hot lower legs who had been started on antibiotics for cellulitis. One staff member removed TED hose from the resident’s weeping left leg and then immediately assessed the right leg without changing gloves or performing hand hygiene. Another staff member, after applying TED hose to the weeping leg while gloved, continued to handle the resident’s food, pillow, and personal items and answered a cell phone by placing her gloved hand into her pocket, all without changing gloves or performing hand hygiene, contrary to the facility’s hand hygiene policy.
The facility failed to protect residents from abuse when one resident without capacity to consent was found in a common area with another resident’s hand inside her brief, and the subsequent investigation did not include interviewing or assessing other residents who might have been affected. In a separate event, a resident shook his spouse’s head and later sprayed water in her face with a spray bottle when she was tired at dinner, causing her agitation, while both continued to share a room and she spent most of her time and slept in common areas due to ongoing behaviors between them, as reflected in her care plan.
Failure to Prevent and Manage Pressure Ulcer Leading to Severe Sacral Wound
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate prevention and treatment of pressure ulcers and to complete and document required skin and wound assessments for a dependent resident. The resident was admitted from a hospital with red skin on the right elbow, a left neck surgical laminectomy site, and a left shin abrasion, and was totally dependent on staff for bed mobility, transfers, dressing, toileting, personal hygiene, and bathing, and had a Foley catheter. Within six days of admission, weekly wound documentation showed the resident had developed bilateral buttock moisture-associated skin damage (MASD) of significant size. The resident was then hospitalized for confusion and hyponatremia, and hospital wound care documented a deep tissue pressure injury to the sacrum that evolved into a Stage III pressure injury with yeast. When the resident returned to the facility, the facility’s readmit screener documented MASD to the buttocks and a yeast rash to the buttocks and groin, but no sacral pressure injury. Subsequent facility wound documentation showed that a few days after readmission, the resident had scattered ulcerations with MASD to the buttocks and a Stage III pressure ulcer to the right medial lower buttock, and that orders for treatment were requested from the physician. By the following week, the weekly wound observation tool documented that the Stage III bilateral buttock wounds had merged into one large unstageable pressure ulcer with odor and moderate purulent drainage, indicating potential infection. During this same period, there were no documented skin/wound assessments for the week leading up to the resident’s transfer back to the hospital, and a staff member later stated she did not know where the assessments were or why they were not done, and could not explain why no one reported that the wound was worsening. The care plan listed multiple skin integrity problems and interventions, including skin evaluations, routine turning and repositioning, CNA skin inspections with routine care, monitoring nutrition, and weekly nurse skin evaluations, but did not specify task frequency for some interventions. Interviews further described staff awareness and handling of the resident’s condition and behaviors. A family member reported that staff were frequently frustrated by the resident’s constant need for attention and anxiety, and that he repeatedly educated management about the resident’s high anxiety and hyperfocus, and did not understand how staff could report spending so much time with the resident yet not recognize how sick he was with infection. A staff member stated the sacral wound was facility-acquired, that the resident became obtunded related to opioids, and that she was unaware of the resident’s excessive water intake until after a hospital stay. Another staff member who completed a readmission history and physical found the resident febrile, with therapy unable to mobilize him due to pain, and described the resident as heavily sedated on an intense pain regimen that predated his stay. This staff member stated there were many opportunities for improvement in nursing assessments and that the facility could not handle the resident’s complex psychiatric and pain needs. Ultimately, the resident was transferred to the hospital with a large sacral decubitus wound with purulent tissue, surrounding cellulitis, and radiologic evidence of a severe sacral ulcer with erosion nearly to the coccyx and associated abscess and necrotizing soft tissue infection.
Improper Labeling, Dating, and Handling of Refrigerated Food Items
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage practices when, during an observation of the walk-in cooler, multiple food items were found undated or unlabeled, contrary to the facility’s Food Safety Requirements policy. Specifically, two zip-lock bags of slimy, sliced tomatoes were not dated; a gallon zip-lock bag of ground meat was not labeled with the food type or date; and separate gallon zip-lock bags of sliced ham, sliced roast beef, and sliced cheese were all undated. In addition, a cup of sliced strawberries had no date. Staff interviews revealed that kitchen staff had observed mold on strawberries upon delivery and would usually attempt to pick out the molded strawberries, and another staff member acknowledged awareness of ongoing dating issues with refrigerated foods. A further interview indicated that moldy dinner rolls had been served on one occasion, prompting staff to retrieve the rolls from residents after service. The facility’s written policy required labeling, dating, and monitoring refrigerated food, including leftovers, so it would be used by its use-by date or frozen/discarded, but these requirements were not followed, placing all residents at risk for foodborne illnesses. No specific residents or their medical histories were identified in the report; the deficiency was described as affecting all residents through improper food labeling, dating, and handling practices in the kitchen and walk-in cooler.
Failure to Submit Abuse and Elopement Investigation Findings Within Required Timeframe
Penalty
Summary
The facility failed to submit investigation findings related to alleged abuse and elopement incidents to the State Survey Agency (SSA) within the required 5 working days for multiple residents. For one incident dated 1/24/26, a resident left her room and kicked another resident’s feet; the facility’s investigative findings for this event were not submitted to the SSA until 2/4/26, which was 11 days after the incident was reported. For another incident dated 3/20/26, one resident kicked another resident in the legs while both were in wheelchairs, with no injuries reported and immediate separation of the residents; review of records showed no evidence that the facility ever submitted investigative findings for this incident to the SSA. Additionally, review of the SSA reporting site showed that the facility made initial reports of elopement for a resident on 7/18/25 and 2/1/26 but did not submit final investigation reports within the required 5 working days. There were no final reports for either elopement incident. During an interview, a staff member stated that another staff member, who was out of the facility during the survey week, was responsible for reporting and submitting investigative findings to the SSA for abuse allegations. The same staff member confirmed the expectation that findings of any abuse allegation be reported to the SSA within 5 working days and acknowledged they could not provide investigative findings for the 3/20/26 incident. The facility’s written policy, reviewed and dated 7/15/25, required that results of all investigations of alleged violations be reported within 5 working days of the incident.
Failure to Investigate Resident Abuse and Elopements or Identify Root Causes
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and manage an allegation of resident-to-resident abuse and multiple resident elopements. In one incident, a resident in a wheelchair kicked another resident multiple times in the lower legs while both were at the nurses’ station. Nursing documentation noted the kicking and that there were no injuries, and the immediate response was to separate the residents. However, review of the facility’s abuse investigations for the relevant period showed no completed investigation related to this reported allegation of resident-to-resident abuse, and there was no documentation of investigative findings or that these findings were reported to the State Survey Agency. The facility also failed to protect the involved residents from further potential abuse. Nursing notes for both residents documented that, two days after the kicking incident, one resident was observed continually attempting to follow, communicate with, agitate, and argue with the other resident, and staff had to separate them twice. Staff communicated to others to monitor their interactions, but the notes showed that the residents continued to have problematic contact, indicating that the facility did not prevent further potential abuse between them. During interview, a staff member stated that another staff person was responsible for investigating and reporting abuse allegations, but that person was unavailable and no documentation could be produced to verify that an investigation had been completed or that results were reported to the state agency, despite facility policy requiring thorough investigation, protection of residents during the investigation, and reporting of results. The deficiency also includes failures related to multiple elopements by several residents. For one resident, an elopement investigation documented that the resident exited the facility, but the investigation lacked signatures, identification of information sources, and clear involvement of the email sender included in the file. A state abuse reporting entry indicated that this resident left through back doors, possibly following a volunteer or staff taking other residents to Mass, and was brought back by a Med-Surg nurse, but there was no documented root-cause analysis or explanation of why the elopement occurred or what interventions were implemented to prevent recurrence. Another resident eloped through doors leading into the hospital; the reportable incident was submitted to the SSA, but there were no nurses’ notes on the date of the elopement describing the event, and a note the following day only stated that the resident attempted to elope twice, reflecting incomplete contemporaneous documentation. For this same resident, the facility’s investigation of the elopement included only limited staff interviews and did not include interviews with CNAs or activity staff to establish a full timeline of the resident’s movements or to identify the root cause. A subsequent elopement by this resident into the hospital was documented in a nursing note, and the investigation consisted of an undated handwritten note stating that people came into the unit looking for someone in the hospital, left to go to Med-Surg, and the resident followed them out the door, with the door alarm functioning and the resident returning to the unit. There was no documented timeline, no detailed interviews, and no analysis of the effectiveness of elopement-prevention interventions. A third resident had multiple documented elopements over several months, with investigation files that often contained only brief summaries, incomplete checklists, or limited supporting documents such as bounds reports or invoices for a wander guard system. Across these events, the facility did not consistently document root-cause analyses or assessments of the resident’s exit-seeking behavior, and the record notes that this failure to identify and document root causes led to a fall with injury for this resident. Interviews with staff confirmed that the facility’s practice did not align with its stated expectations. One staff member reported that a former staff person had previously conducted incident investigations but had left months earlier, and that the expectation for investigations was to determine the root cause of incidents and monitor residents to ensure interventions were implemented. Another staff member stated that after each elopement, the nurse would file a report to the SSA and update the care plan, after which management was supposed to conduct a full investigation. A further interview indicated that nurses entered occurrence reports and submitted SSA reports to track elopements and that staff discussed root causes but did not maintain documentation of those analyses. These statements, combined with the incomplete and inconsistent investigation records, demonstrate that the facility did not carry out or document thorough investigations, root-cause analyses, or protective measures as required by its own abuse investigation and reporting policy.
Failure to Prevent Elopements and Respond to Anti-Wandering Alarms
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and effective interventions to prevent elopements for multiple residents identified as at risk for wandering, despite existing assessments and care plans. Staff reported that residents at risk for elopement were identified by the MDS nurse on admission and quarterly, and that anti-wandering devices and door alarms were in place, particularly at the front door. However, staff also indicated that wander guard bracelets could be applied without formal assessment, and that information about elopement risk was communicated via paper “brain” sheets. The facility had a written SBAR and procedure for anti-wandering door alarms, including immediate resident location checks and following an elopement procedure, but the report shows these processes were not effectively implemented. One resident with a documented elopement risk and dementia was care planned to have an anti-wander device on her wheelchair and to be involved in activities and redirected when she attempted to exit. She eloped on at least two occasions: once when she went through the first set of doors and was found in a corridor by another resident, and another time when she exited through back doors, apparently following others going to Mass, with no alarms triggered. Her care plan documentation was inaccurate regarding the presence of a wander guard door in 2024, and there was no nursing documentation of the February elopement in her electronic health record. Another resident with severe cognitive impairment (BIMS score of 3) and an elopement risk care plan that included redirection, diversional activities, and ensuring door alarms were activated, was able to get out between the sliding front doors when someone was entering or exiting, and no one saw her leave, contrary to the care plan interventions. A further resident with dementia and short-term memory problems was identified as at risk for elopement, yet his elopement care plan and interventions were not initiated until after he had already eloped twice in one afternoon through different doors. He later eloped again, but the corresponding nursing note was not provided. Another resident, described as exit seeking and very independent with behavioral issues toward staff, had an anti-elopement alarm device on her wheelchair that sounded as she approached the door and had been near the door setting off the alarm throughout the day. Despite this, she was able to push open the main entrance sliding doors, exit, and then fall while attempting to walk down stairs, sustaining an abrasion and bruising and requiring hospital evaluation. Staff interviews indicated that interventions such as 1:1 monitoring, taking her outside, and diversional tasks were used, and that elopements were tracked via occurrence reports and state submissions, but the facility failed to identify the need for continuous one-on-one monitoring for this resident, failed to respond appropriately to the anti-elopement door alarm, and failed to prevent her unsupervised exit and subsequent fall. Activity staff also reported that, after a staffing reduction, there were no organized activities after 5 p.m., despite prior recognition that increased monitoring and activities during late afternoon hours were needed for an elopement-risk resident.
Failure to Provide Meaningful Activities for Dementia Residents in Memory Care Unit
Penalty
Summary
The deficiency involves the facility’s failure to provide meaningful, resident-centered activities to meet the needs of multiple residents with dementia in the memory care unit. Surveyors observed residents sitting in dining and common areas without any activities, including a resident with a BIMS score of 0 repeatedly scratching her arms while staring at a turned-off television, and another resident wandering the unit and running into walls. On another observation, the scheduled activities were canceled due to weather, and the activity staff member present was working on care plans on a computer while residents sat with newsletters in front of them, many staring at the floor or sleeping. Only some residents participated in the offered activities, while others, including residents with severely and moderately impaired memory, did not participate and were not engaged. During the same observation period, residents were given a word search activity, but only a few actively worked on it. Sitters, who were present to watch and redirect residents, sat at the tables and did not attempt to assist residents with the activity. One resident repeatedly stated she needed her glasses to see the paper, but no staff obtained her glasses. A resident who did not speak English sat staring down the hall without engagement, and another resident with severe cognitive impairment wandered the hall. The activity staff member stated she had other duties in another unit and left, and later that evening, surveyors observed one resident sleeping in a recliner and another staring at a wall while cartoons played on the television. Interviews with staff revealed that activities in the memory care unit were limited and often not implemented as scheduled. The activity staff member reported she was instructed by management to avoid music and physical activities because staff believed these would cause residents to become agitated, and that she was told to limit activities to calming options only. She also stated that residents were often left in bed and not taken to activities because it was easier for staff, and that floor staff did not provide activities when she was not present, preferring residents to sit quietly. Other staff confirmed that activities usually did not occur in the memory care unit, that activities observed during the survey were a show for surveyors, and that the activity calendar was not followed. The memory care activity calendar showed “Resident Choice Day” on all weekends and listed trivia, exercise/stretching, and book club on weekdays, while the facility’s activities policy required activities to enhance well-being, physical activity, cognition, and to provide meaningful activities for residents with dementia.
Failure to Assess Hospice Resident’s Polypharmacy and Sedation Risk
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s drug regimen was free from unnecessary medications and thoroughly assessed for sedation, duplicate therapy, and adverse consequences. A hospice resident with metastatic cancer, delirium, psychosis, and impulsive, intermittently aggressive behavior was receiving multiple medications including antipsychotics, opioids, benzodiazepines, and a steroid. Hospice staff discontinued some medications and added morphine and lorazepam, while the resident also continued on quetiapine, hydrocodone, prednisone, and later received a one-time dose of olanzapine. Facility staff A and B reported that they had no concerns with the resident’s medications despite the combination of psychotropic and sedating drugs. The resident had been ambulatory on arrival to the facility but became weaker with multiple falls, nonsensical and incoherent speech, and combative and unsafe behavior. One-to-one supervision was initiated due to impulsivity and aggression, and staff questioned whether pain contributed to the aggressive behavior. The resident’s pain scores documented on the Medication Administration Record over three days showed moderate to severe pain levels (5/10, 3/10, and 7/10), while the resident continued to receive multiple sedating medications, including quetiapine every eight hours, hydrocodone three times daily, lorazepam as needed every four hours, morphine as needed every four hours, and prednisone daily. On the day before transfer to the hospital, the resident received olanzapine, prednisone, hydrocodone, two doses of lorazepam, and morphine; on the day of transfer, the resident received lorazepam, morphine, and prednisone. When a family member arrived at the facility, they found the resident unconscious with minimal response to painful stimuli and appearing sedated, and they requested transfer to the hospital. The family reported the resident had been more sedated at the facility lately, and the emergency room provider reportedly told the family the resident had an overdose of medications. Hospital documentation noted altered mental status, hypoxia, and that the resident’s dementia and chronic encephalopathy may have been exacerbated by disease progression and opioid use, possible steroid-induced psychosis, and electrolyte imbalance. The facility did not identify or address the resident’s medication regimen as a contributing factor to sedation or assess for duplicate therapy and adverse consequences prior to the resident’s transfer.
Failure to Monitor and Treat Constipation in Resident With Opioid-Induced Constipation History
Penalty
Summary
The facility failed to monitor and manage constipation for a resident with a known history of opioid-induced constipation and prior use of constipation medications. Hospital records showed the resident had been admitted with a 9.6 cm fecal impaction and that the hospital physician documented the resident could go up to five days without a bowel movement, likely due to opioid use, and was working on balancing opioid-induced constipation with constipation medications. Upon admission to the facility, the Admit/Readmit Screener documented that the resident had normal formed stool and rarely or never depended on laxatives, despite this history. Facility bowel documentation later showed gaps in bowel movements, including no bowel movement for several days. Review of the Medication Administration Record for March and April showed the resident did not receive any scheduled or PRN constipation medications during the stay. Bowel documentation indicated no bowel movement from 3/29 to 4/3, followed by diarrhea on 4/4 and a putty-like stool on 4/5. A nursing progress note on 4/6 documented a flat, non-tender abdomen with no bowel sounds and no constipation, while hospital records from the same date, after readmission, showed an extensive stool burden distending the rectum to 8.8 cm with findings concerning for stercoral colitis. Staff interviews revealed that no one reported the resident had gone six days without a bowel movement, the resident had gone without any PRN bowel medications, and the facility did not have a policy specific to bowel and bladder management.
Failure to Perform Hand Hygiene During Wound and Skin Care
Penalty
Summary
Facility staff failed to ensure proper hand hygiene during care of a resident with suspected infected lower extremities. During an observation, two staff members entered the room of a resident who had reported weeping and hot lower legs. One staff member removed the TED hose from the resident’s left leg, noted that the leg was hot to the touch and weeping edema fluid, then moved directly to the right leg, removed the TED hose, and assessed that leg without changing gloves or performing hand hygiene between contact with the weeping left leg and the intact right leg. This same staff member later stated she believed she had completed all hand hygiene opportunities but realized, when questioned, that she had moved from one leg to the other without performing hand hygiene. The resident had been started on Cipro for cellulitis on the morning of the observation. A second staff member returned to the room with new TED hose and socks, donned gloves, and assisted with applying the TED hose. This staff member applied TED hose to the resident’s left leg, observed weeping fluid from the skin, and then proceeded to clean up the room while still wearing the same contaminated gloves. While gloved, she touched the resident’s food on the bedside table, handled the resident’s pillow and placed it on the chair where the resident was sitting, and put her gloved hand into her clothing pocket to turn off her ringing cell phone. She did not perform hand hygiene or change gloves after contact with bodily fluids and before touching other items in the room. After leaving the room, she stated she had not thought about performing hand hygiene after finishing application of the TED hose. The facility’s hand hygiene policy required hand hygiene after handling contaminated objects, when moving from a contaminated site to a clean body site during resident care, and after handling items potentially contaminated with blood or bodily fluids.
Failure to Protect Residents From Sexual and Physical Abuse by Other Residents
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from abuse, including sexual and physical abuse, by other residents. In one incident, a resident without capacity to consent was found in a common area with another resident’s hand inside her brief up to the wrist. Staff immediately separated the residents, and the incident was reported to the State Survey Agency; however, the facility’s investigation did not include interviewing or assessing other residents who might have been present or potentially affected by similar sexual abuse incidents. A staff member also reported that the incident was initially reported under the wrong license type because they were unaware the facility held both an adult day care and a skilled nursing facility license. In a separate incident, a resident became upset with his spouse, also a resident, during dinner and shook her head to wake her, then later sprayed water in her face with a spray bottle after staff had intervened and moved her to the nurses’ station. The spouse became agitated by these actions. Observations showed that the couple continued to share a room, with both residents’ nameplates and belongings present. Staff interviews indicated that the spouse who was the target of the behavior was usually kept out of the room and spent most of her time and slept in common areas or by the nurses’ station due to ongoing behaviors between the two. The care plan for the spouse reflected that she was not to be in the room when her husband was present unless both wanted to be there, and staff were to intervene if yelling occurred, based on the prior incident of head shaking and use of the spray bottle.
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