Livingston Health & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Livingston, Montana.
- Location
- 510 S 14th St, Livingston, Montana 59047
- CMS Provider Number
- 275047
- Inspections on file
- 23
- Latest survey
- November 18, 2025
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Livingston Health & Rehabilitation Center during CMS and state inspections, most recent first.
Staff failed to thoroughly investigate and address two incidents of neglect, including inadequate bowel and bladder care for several dependent residents and incomplete medication and treatment documentation for over twenty residents. Staff interviews revealed gaps in training on neglect and medication administration, with provided materials focusing only on sexual abuse. Internal quality assurance processes were insufficient, with no formal QAPI meeting held and delayed reporting to the nursing board.
A nurse failed to complete required medication administration and care documentation for 23 residents during a night shift, resulting in missing or late medications and unrecorded treatments. Residents and staff reported concerns about missed doses, and facility records showed numerous incomplete MARs and care tasks, particularly for residents with complex medical needs. The nurse stated she intended to complete documentation later due to a migraine, but this was not communicated to the oncoming staff.
Licensed nursing staff neglected to assess and manage pain and anxiety for a hospice resident in end-of-life transition, resulting in a 17-hour gap between morphine doses and no administration of lorazepam for anxiety. The nurse on duty did not document assessments or interventions for the resident's restlessness, and the lack of care negatively affected the resident's comfort.
A resident suffered a large hematoma and swelling to the left lower extremity after staff performed a manual stand pivot transfer instead of using a hoyer lift as required. The incident was caused by lack of updated care plan information, poor communication between therapy and nursing staff, and failure to ensure the proper transfer equipment was in place.
Facility staff did not submit investigative findings for two residents with injuries of unknown origin within the required timeframe. In both cases, the responsible staff member mistakenly saved rather than sent the reports, resulting in late submission to the State Survey Agency.
A resident's care plan was not updated to reflect changes in transfer ability after new PT documentation indicated transfer goals were discontinued due to pain and lack of participation. The care plan continued to state the resident could transfer with assist of one, despite evidence to the contrary, and the resident later sustained a hematoma likely related to a difficult transfer. Staff interviews confirmed the care plan was not revised as required.
Staff did not consistently use PPE or perform hand hygiene when providing care to residents on enhanced barrier or contact precautions, including during wound care and meal assistance. In several cases, staff were unaware of or did not follow posted precaution signage, and necessary PPE supplies and disposal containers were not available. The facility also lacked proper documentation and procedures to prevent legionella, with missing temperature logs and no flushing of unused toilets.
Surveyors found multiple expired stock medications in the medication cart, including sodium chloride, guaifenesin, various vitamins, aspirin, and stool softener capsules. A staff member stated that auditing for expired medications was a shared responsibility among nursing staff, but expired medications were still present despite facility policy requiring immediate removal and disposal.
A resident who was independent with showering reported feeling unsafe due to a slippery tiled wall that could not be used for support and an emergency pull cord that was not within reach from the shower chair. Staff confirmed the pull cord's placement was not accessible, and the resident stated previous concerns had not been resolved.
A resident's privacy was not maintained during a brief change when a staff member only partially closed the privacy curtain and left the window curtain open, exposing the resident to view from a public patio. The staff member admitted to forgetting to close the window curtain, and the resident expressed concern about being seen.
A resident's room was found to be unclean, with liquid spills, dirt, dust, and debris present over multiple days. The resident expressed frustration about the inability to move his bedside table due to the dirty floor and reported that housekeeping had not cleaned the room all week. Staff confirmed that rooms were not being cleaned daily as required, citing staffing shortages.
Nursing staff did not maintain or follow current physician orders for wound care for two residents, resulting in periods without appropriate orders and the use of unclear or inappropriate dressing protocols. One resident with a heel pressure injury lacked a physician order for several days, while another with surgical incisions received dressing care that did not match the physician's recommendations until orders were clarified.
A resident did not have documentation of receiving or declining a pneumonia vaccine, as required by facility policy. An audit identified missing consents for this and other residents, and review of records confirmed the absence of the necessary immunization review and administration.
Two residents experienced severe weight loss due to the facility's failure to monitor and address their nutritional needs. One resident lost 17% of their body weight over 42 days, while another lost 12.1% over 63 days. The facility did not implement timely dietary interventions, failed to update care plans, and did not provide fortified meals as ordered. Deactivated weight loss alerts further delayed necessary assessments and interventions.
A resident with severe cognitive impairment and chronic pain was inadequately managed by the facility staff, leading to ongoing distress and a decline in her condition. Despite frequent expressions of pain, the staff failed to update her pain management plan or respond effectively to her needs, resulting in significant suffering and reduced quality of life.
The facility failed to maintain sufficient nursing staff and ensure a licensed nurse was always present. During a night shift, an LPN and a CNA left the facility, leaving only one CNA to care for 44 residents. This absence led to inadequate care, with one resident missing medication and others left wet and soiled. Attempts to contact the absent staff were unsuccessful.
The facility's dietary department was understaffed, causing meal service delays and unmet resident preferences. Observations showed meals were served late, with non-dietary staff assisting due to insufficient dietary personnel. Expired nutritional drinks and compromised kitchen cleanliness were noted. Residents experienced significant delays, with some meals served over an hour late, and preferences not followed, leading to meal refusals.
The facility's kitchen and dietary storage areas were found to have multiple sanitation issues, including soiled equipment, improperly stored and labeled food, and expired items, increasing the risk of foodborne illnesses. Staff interviews revealed a lack of awareness and understaffing, contributing to the deficiencies. Additionally, reviews of sanitation and food temperature logs showed lapses in maintaining proper protocols.
A facility failed to report an allegation of neglect within 24 hours when an LPN and a CNA left their shift, leaving 44 residents without licensed nurse coverage. The incident occurred during a night shift, with only one CNA remaining to care for the residents. Attempts to contact the absent staff were unsuccessful, and the incident was not reported to the State Survey Agency until days later. The facility's investigation was still ongoing.
The facility failed to properly investigate and intervene in cases of resident-to-resident abuse. In one case, two residents involved in a verbal and physical altercation were not kept separated as instructed, leading to further issues. In another case, a resident was placed with a roommate she did not get along with, resulting in frequent verbal altercations and distress. Staff were unaware of necessary interventions, and care plans were not updated.
The facility failed to update care plans for three residents involved in incidents of altercations, weight loss, and pain management. Two residents had a physical altercation, but their care plans were not updated to reflect the incident or necessary interventions. Another resident's care plan was not updated to reflect dietary changes recommended by a dietitian, and it contained multiple inaccuracies and incomplete sections.
A resident was discharged without proper preparation, lacking a finalized home health referral and necessary medications, including fentanyl patches. The discharge transition plan was incomplete, with no documentation of medication quantities or scheduled doses, and the responsible social service staff was unavailable, leading to the Business Office Manager assisting with discharges.
The facility did not provide evidence of investigation or follow-up for two incidents of resident-to-resident verbal abuse. In one case, a resident threatened another, leading to the removal of the threatened resident for safety. In another case, two cognitively impaired residents were separated after a verbal altercation. Despite reporting these incidents to the State Survey Agency, the facility failed to submit investigation findings.
The facility's medication error rate was 15%, exceeding the acceptable threshold of 5%. A staff member administered an incorrect dose of Sodium Chloride to a resident, and another staff member failed to prime insulin pens before administering Insulin Glargine and Insulin Aspart to a resident. These actions violated the facility's medication administration policies.
The facility's dietary department was understaffed, leading to delayed meal service and unmet resident preferences. Observations and interviews showed meals were served late, with residents expressing dissatisfaction. Only five staff members, including the manager, were available, despite the facility's assessment indicating a need for eight. This staffing shortage affected all residents receiving meals, as staff struggled to maintain timely service and address preferences.
A staff member left Cephalexin capsules at a resident's bedside for self-administration without obtaining a physician's order. Upon questioning, the staff member realized the error and observed the resident taking the medication. The resident's medical record did not contain a self-administration order.
A resident with low cognitive function was found on the floor with a major injury, including a pelvic fracture and significant blood loss, requiring hospitalization. The unwitnessed incident was not reported to the State Survey Agency as an unknown injury. A staff member believed it had been reported but it was not.
The facility failed to provide baseline care plan summaries to three residents or their representatives. Interviews revealed that a staff member was unaware of a resident's care plan, while two residents had not participated in care plan discussions. Staff member G noted that social services usually handle care plan meetings and signatures, but no evidence of signed care plans was found in the residents' EHRs.
A facility failed to provide proper wound care for a resident with a Stage 2 pressure injury, missing multiple dressing changes and not applying prescribed materials. Documentation inconsistencies and lack of staff audits or education contributed to the deficiency.
The facility failed to manage the communal resident personal food refrigerator and freezer properly. Staff were uncertain about who was responsible for monitoring, cleaning, and checking temperatures, leading to improperly stored food and discarded groceries. A resident expressed frustration over the loss of her groceries, which were essential for her nutritional needs. Despite a facility policy outlining procedures for food management, these were not adhered to.
Failure to Investigate and Address Neglect and Medication Documentation Deficiencies
Penalty
Summary
Facility staff failed to conduct a thorough investigation and implement comprehensive corrective actions following two separate incidents involving allegations of neglect. On one night shift, multiple dependent residents assigned to a specific staff member were found in the morning heavily soiled with urine and feces, indicating a lack of appropriate bowel and bladder care. On another night shift, a resident reported not receiving morning medications, which led to the discovery that a nurse had failed to document medication and treatment administration for a significant number of residents during her shift. Review of records confirmed that medication and treatment administration records were incomplete, and there was no verification for non-controlled medications using the facility's blister pack system. Interviews with staff revealed inconsistencies and gaps in training related to abuse, neglect, and medication administration. Several staff members reported only receiving a review of the abuse policy, with training content focused on sexual abuse rather than neglect or medication documentation. Some staff could not recall receiving any recent training on these topics, and there was confusion about the applicability and adequacy of the training provided. Documentation provided by the facility supported these accounts, showing that the abuse and neglect training materials were limited in scope and did not address the specific deficiencies identified. Further, the facility's internal processes for investigation and quality assurance were found lacking. While some staff reported informal or ad hoc meetings to discuss the incidents, there was no evidence of a formal QAPI meeting to address the quality-deficient practices or to develop needed corrections. Key staff members were not notified or included in these meetings, and documentation of required notifications to the state nursing board was delayed. No evidence was provided to show that comprehensive education on medication administration and documentation was completed for licensed staff as required.
Failure to Ensure Medication Administration and Documentation Meets Professional Standards
Penalty
Summary
A facility nurse failed to provide nursing services in accordance with professional standards for medication administration and documentation for 23 out of 24 sampled residents. The nurse did not complete required documentation for medication administration, treatments, and monitoring as ordered by physicians during a 12-hour night shift. Multiple residents' Medication Administration Records (MARs) and treatment records were left incomplete, with numerous required tasks such as pain monitoring, psychotropic side effect monitoring, oxygen saturation checks, and medication applications not documented as performed. In some cases, medications were documented as administered in the MAR, but residents reported not receiving them. Interviews with residents and staff revealed concerns about missed or late medications, with one resident specifically stating she did not receive her thyroid medication and had filed a grievance. Staff members reported frequent complaints about the nurse in question, including uncertainty about whether medications had been given. An internal investigation by facility staff confirmed that the nurse had not completed documentation for 21 residents during the shift, and the electronic medical record system highlighted these omissions. The nurse claimed to have completed all required work but intended to enter documentation as late entries due to a migraine, which was not reported to the oncoming nurse. Review of the MARs and facility investigation showed that essential care tasks and medication administrations were not documented for a wide range of residents, including those with complex medical needs such as hospice care, anticoagulation therapy, and enhanced barrier precautions. The lack of documentation made it unclear whether residents received their ordered medications and treatments, and in some cases, residents with cognitive impairment were unable to confirm whether care was provided. The facility's review referenced professional standards for nursing documentation, emphasizing the need for timely, accurate, and comprehensive records, which were not met in this instance.
Failure to Assess and Manage Pain and Anxiety in Hospice Resident
Penalty
Summary
Licensed nursing staff failed to provide necessary services to a hospice resident in end-of-life transition by not adequately assessing and treating pain and anxiety. The resident, who had a history of restlessness and agitation managed with as-needed lorazepam for anxiety and morphine for pain, received only one dose of morphine and no lorazepam during a 12-hour night shift. Documentation confirmed a 17-hour gap between morphine doses, and there was no record of lorazepam administration for anxiety during this period. The nurse on duty was inconsistent in her account of medication administration and did not recognize that the resident's restlessness could be related to pain or anxiety. Review of the medication administration record and nursing progress notes revealed a lack of documentation regarding assessments or interventions for the resident's restlessness, pain, or anxiety during the shift in question. The absence of timely pain and anxiety management negatively affected the resident's comfort, and the facility's investigation corroborated the neglect of care provided to the resident during this period.
Resident Injury Due to Improper Transfer and Communication Breakdown
Penalty
Summary
A resident sustained a significant injury to the left lower extremity, including swelling and bruising described as the size of a tennis ball, after being transferred incorrectly by staff. The incident occurred when staff attempted to transfer the resident from a wheelchair to bed without using the required hoyer lift, instead performing a stand pivot transfer with a gait belt and three staff members present. The transfer was made more difficult because the resident was very weak, and the proper sling for the hoyer lift was not in place. The nurse documented the injury and noted the resident reported an accident had occurred. Review of the resident's care plan showed it was outdated, indicating the resident could transfer with one person assisting, with no updates reflecting the current need for a hoyer lift. Staff interviews revealed confusion and lack of communication between nursing and therapy staff regarding the resident's transfer status. Therapy had used a slider board earlier in the day and did not leave a sling under the resident, which contributed to the improper transfer method being used by nursing staff. The facility's investigation determined the injury likely resulted from this difficult and incorrect transfer.
Failure to Timely Report Investigative Findings for Resident Injuries
Penalty
Summary
Facility staff failed to report investigative findings for reportable events within the required timeframe for two residents who sustained injuries of unknown origin. In the first case, a resident developed a hematoma on the left lower extremity, and although the incident was initially reported to the State Survey Agency, the investigative findings were not submitted until two days after the deadline. In the second case, another resident experienced swelling and bruising to the right hand, and the investigative findings were also reported two days late. Staff member A, responsible for submitting these reports, stated that in both instances he mistakenly pressed the save button instead of the send button in the reporting system and did not realize the error until after the deadline had passed. Additionally, for the second incident, staff member A expressed uncertainty about whether the event should have been reported but ultimately did so as an unknown injury.
Failure to Update Care Plan Following Change in Transfer Ability
Penalty
Summary
The facility failed to update a resident's care plan to accurately reflect the resident's current ability to transfer from a wheelchair to a bed. A facility-reported incident revealed that the resident sustained a hematoma of unknown origin to the left lower extremity, which the facility's investigation determined likely resulted from a difficult transfer. Interviews with staff confirmed that care plans are supposed to be updated when new physical therapy (PT) orders are received, but in this case, the care plan was not revised to reflect the resident's updated transfer status and abilities as documented in PT progress notes. The care plan continued to state that the resident could perform all transfers with assist of one, despite PT documentation indicating that transfer goals had been removed due to the resident's pain and unwillingness to work on transfers. No updates to the care plan regarding transfer status were found after the initial entry.
Failure to Implement Infection Control Practices and Documentation
Penalty
Summary
Staff failed to consistently implement appropriate infection prevention and control practices, particularly regarding the use of personal protective equipment (PPE) and hand hygiene. Multiple staff members did not don required gowns and gloves when providing high-contact care to residents on enhanced barrier precautions (EBP) for wounds or indwelling devices. For example, staff provided personal care, transferred residents, changed dressings, and handled soiled linens without wearing the necessary PPE or performing hand hygiene between glove changes. In some cases, staff were unaware of the current precaution status of residents or did not follow posted EBP signage, and one resident reported that staff did not use PPE during dressing changes for surgical wounds. Staff also failed to follow transmission-based precautions for residents on contact precautions. Observations revealed that staff entered rooms and provided direct care, such as repositioning and transferring, without donning gloves or gowns as required. In one instance, a resident with a contact precaution sign for pink eye reported that staff never wore PPE, and there was no PPE cart or appropriate disposal containers available. Staff interviews confirmed inconsistent understanding and application of PPE protocols for residents with infectious conditions. Hand hygiene practices were deficient during meal assistance, as staff were observed feeding multiple residents without performing hand hygiene between residents or after touching food items. Additionally, the facility did not maintain adequate documentation or procedures to prevent legionella growth, such as flushing unused toilets or maintaining complete temperature logs. Staff were unaware of specific protocols for legionella prevention, and there were missing records for several months, especially in unused areas of the facility.
Expired Stock Medications Not Removed from Medication Cart
Penalty
Summary
Surveyors observed that expired stock medications were present in the medication cart, including bottles of sodium chloride, guaifenesin, vitamin B-6, folic acid, enteric coated aspirin, vitamin B-12, aspirin, stool softener capsules, and vitamin A, all with expiration dates that had already passed. During an interview, a staff member indicated that the responsibility for auditing expired stock medications was shared among herself and the nursing staff. Review of the facility's policy confirmed that outdated, contaminated, discontinued, or deteriorated medications are to be immediately removed from stock and disposed of according to established procedures. Despite this policy, expired medications remained accessible in the medication cart at the time of the survey.
Inaccessible Emergency Pull Cord and Unsafe Shower Environment
Penalty
Summary
The facility failed to provide a safe environment in the shower room for one resident who was independent with showering. The resident reported feeling unsafe due to a slippery tiled wall that was too thick to grasp for support and expressed concern about the location of the emergency pull string station, which was situated on the other side of the half tiled wall and not within reach from the shower chair. The resident stated she had previously reported these concerns to management but felt that no resolution had been provided. Staff interviews and observations confirmed that the placement of the pull cord station was not accessible to residents while showering, supporting the resident's concerns about safety in the shower room.
Failure to Ensure Resident Privacy During Personal Care
Penalty
Summary
The facility failed to ensure resident privacy during personal care for one resident. On two separate occasions, a resident was observed lying in bed near a window that faced a public patio area. During a brief change, a staff member only partially closed the privacy curtain and did not close the window curtain, resulting in the resident's backside being exposed and visible from the outside patio. The staff member later acknowledged forgetting to close the window curtain. The resident expressed concern about the possibility of being seen from outside during the care activity.
Failure to Maintain Clean and Safe Resident Living Area
Penalty
Summary
A deficiency was identified when a resident's living area was observed to be unclean and not maintained in a safe, comfortable, or homelike manner. During two separate observations, the resident's room had multiple areas with liquid spills, dried dirt, dust, and debris, including treatment syringe caps, a wrapped piece of candy, and dust bunnies entangled with cables. The resident reported frustration with the condition of the room, specifically noting difficulty moving his bedside table due to the dirt on the floor. The resident also stated that housekeeping had not been in his room all week, despite his expectation of regular cleaning. Staff interviews revealed that only one staff member was responsible for cleaning rooms during the week, with two additional staff available only on weekends. The staff member confirmed that resident rooms should be cleaned daily but acknowledged that, due to staffing shortages, rooms were only being cleaned every other day. The lack of adequate cleaning and maintenance directly contributed to the resident's dissatisfaction and the unclean state of the living environment.
Failure to Maintain and Follow Current Physician Orders for Wound Care
Penalty
Summary
The facility failed to ensure that physician orders for wound care were completed, current, and followed by nursing staff for two residents. For one resident with a left heel deep tissue injury, there was no physician order in place for a period of several days, and staff were unable to explain the absence of the order. During this time, the resident's stable eschar was left open to air, and offloading with pillow boots continued, but the lack of a documented order meant that care was not guided by current physician instructions. For another resident with bilateral below-the-knee amputation surgical incisions, the physician order for dressing changes was found to be vague and required clarification. Staff used various dressings, including ace wraps, which were later determined to be inappropriate for the surgical incisions. The physician's specific recommendations for wound care were documented in a progress note but were not reflected in the active orders until several days later, resulting in dressing changes that did not align with the intended treatment plan.
Failure to Review and Administer Required Immunizations
Penalty
Summary
The facility failed to ensure that immunizations were reviewed and administered for one of twenty-four sampled residents. During an interview, a staff member reported that an audit revealed missing consents for several residents, including the affected individual. Review of the resident's electronic health record and the State of Montana Official Immunization Record showed no documentation of pneumonia vaccines being administered or declined for this resident. The facility's policy requires pneumococcal vaccination upon admission after review, with repeated vaccination per CDC guidelines, but this was not followed for the resident in question.
Failure to Address Severe Weight Loss in Residents
Penalty
Summary
The facility failed to adequately monitor and address significant weight loss in two residents, leading to severe health deficiencies. Resident #47 experienced a severe weight loss of 17% over 42 days, with inadequate monitoring and lack of timely interventions. The resident was not weighed regularly, and despite a significant weight loss, no dietary changes or supplements were introduced. The care plan lacked any nutritional interventions, and the resident continued to lose weight until discharge. Resident #71 also suffered from severe weight loss, losing 12.1% of her body weight over 63 days. The care plan was not updated to reflect necessary dietary changes, and there was a significant delay in implementing the dietitian's recommendations. The resident's pain and inadequate food intake were not properly evaluated, and the facility failed to provide fortified meals as ordered by the physician. The weight loss alerts were deactivated, preventing timely assessments and interventions by the dietitian. The facility's inaction and lack of timely response to the residents' nutritional needs resulted in severe weight loss and inadequate care. The failure to monitor weight changes, update care plans, and implement dietary interventions in a timely manner contributed to the deficiencies observed in the care of residents #47 and #71.
Inadequate Pain Management for Cognitively Impaired Resident
Penalty
Summary
The facility nursing staff failed to adequately assess and manage the pain of a resident with a history of severe cognitive impairment and multiple pain-related diagnoses, including a wedge compression fracture and chronic pain. Despite the resident's frequent expressions of pain, such as crying and calling out, the staff did not update the pain management care plan to include non-pharmacological interventions or reassess the effectiveness of the current pain management strategies. The resident's pain management regimen included various medications, but there were inconsistencies in administration and documentation, as evidenced by the resident's continued expressions of pain and the lack of timely response to her needs. The resident's medical records indicated a series of medication changes and discontinuations without clear documentation of the rationale or assessment of their impact on the resident's pain levels. For instance, the hydromorphone was discontinued at the resident's request, despite her severe cognitive impairment, which should have prompted a more thorough evaluation by the staff. Observations and interviews revealed that the resident's pain was not consistently documented, and her cries for help were often ignored or inadequately addressed, leading to a decline in her physical condition and ability to participate in daily activities. Interviews with staff and other residents highlighted a lack of responsiveness to the resident's pain, with reports of the resident being left in pain for extended periods and not being repositioned regularly due to her discomfort. The resident's inability to effectively communicate her pain needs, combined with the staff's failure to proactively manage her pain, resulted in significant distress and a decrease in her quality of life. The facility's inadequate pain management practices were evident in the resident's ongoing suffering and the staff's apparent neglect in addressing her needs.
Insufficient Staffing and Nurse Absence
Penalty
Summary
The facility failed to ensure sufficient nursing staff were available to meet the needs of residents and maintain a licensed nurse on duty at all times. On the night shift of December 25, 2024, the facility was staffed with one licensed nurse and two certified nurse assistants (CNAs). However, the licensed nurse and one agency CNA left the facility together, leaving only one CNA to care for 44 residents. This resulted in a lack of licensed nurse coverage for an unspecified period. Staff member A reported that the nurse documented a refusal of one medication, although the resident wanted to be awakened for her routine anti-anxiety medication. Attempts to contact the nurse and CNA were unsuccessful, and the interim staffing agency was involved in trying to reach them. Staff member I, who worked on the same shift, confirmed that the LPN and CNA left the facility around 12:15 a.m. and returned more than one and a half hours later. During their absence, staff member I attempted to contact the nurse via walkie-talkie but received no response. She also texted the Director of Nursing (DON) but did not receive any feedback. Staff member I was left to manage resident rounds, answer call lights, and ensure resident safety. Upon returning to work on December 27, 2024, staff member I was questioned by another CNA about why many residents were left wet and soiled. Resident #66 expressed a desire to be woken up for her medication at night but could not recall if she had missed any doses.
Dietary Staffing Shortages Lead to Meal Service Delays
Penalty
Summary
The facility failed to provide sufficient staffing in the dietary department, leading to delays in meal service and unmet resident preferences. Observations and interviews revealed that the kitchen was short-staffed, affecting the timeliness and quality of meal service. Meals were served late, with breakfast, lunch, and dinner not being served at the scheduled times. Non-dietary staff had to be called in to assist with meal service, indicating a lack of adequate dietary personnel. Additionally, expired nutritional drinks were found in the kitchen, and the cleanliness of the kitchen was compromised due to staffing shortages. Residents experienced delays in receiving their meals, with some meals being served over an hour past the scheduled time. There were instances where resident preferences were not followed, leading to meal refusals and further delays. Staff interviews confirmed the understaffing issue, with reports of insufficient training and lack of a cleaning schedule. The dietary staffing schedule showed multiple days with inadequate staffing, further contributing to the deficiency in providing timely and satisfactory meal services to residents.
Sanitation and Food Safety Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen and dietary storage areas, leading to an increased risk of foodborne illnesses for all residents receiving food from the kitchen. Observations during the initial tour revealed multiple sanitation issues, including soiled hot chocolate and juice machine nozzles, improperly stored small bowls, and heavily soiled cooler handles. Additionally, numerous food items in the coolers were either unlabeled, undated, or expired, such as souffle cups, mixed fruit, almond milk, nutritional drinks, and cottage cheese. Dented cans of beets were found on a shelf labeled 'use first,' and the cleaning bucket lacked a sanitizing agent. The resident refrigerator was also found with stains and uncleaned spills. Interviews with staff members highlighted issues with staffing and awareness of the kitchen's condition. Staff member B was unaware of outdated nutritional drinks and stated that leftover food should be discarded after three days. Staff member C mentioned that dented cans should be returned for credit and noted that staffing was improving but still insufficient at times. Staff member F, who recently started working at the facility, confirmed the kitchen was severely understaffed and was unaware of any cleaning schedule. The review of sanitation bucket chemical results and food temperature logs further indicated lapses in maintaining proper sanitation and food safety protocols.
Failure to Report Neglect and Absence of Licensed Nurse Coverage
Penalty
Summary
The facility failed to report an allegation of resident neglect within 24 hours of the incident, which involved a licensed nurse and a certified nurse assistant leaving the facility during their shift. This left 44 residents without licensed nurse coverage, increasing the risk of harm or negative outcomes. The staffing schedule indicated that the facility was supposed to have one licensed nurse and two certified nurse assistants on duty during the night shift. However, the licensed nurse and one agency CNA left the facility together, leaving only one CNA to care for all the residents. Staff member A was unaware of how long the facility was without licensed nurse coverage and did not know if any residents missed medications. Staff member I confirmed that the LPN and CNA left the facility around 12:15 a.m., taking a walkie-talkie with them and instructing her to use hers if needed. After approximately 30 minutes, staff member I attempted to contact the nurse via walkie-talkie but received no response. The nurse and CNA returned more than 1.5 hours later. During their absence, staff member I tried to manage resident care and safety alone, noting that no residents fell during this time. However, upon returning to work, she was informed that many residents were left wet and soiled. The incident was not reported to the State Survey Agency until several days later, and the facility's investigation was still ongoing at the time of the report.
Failure to Investigate and Intervene in Resident-to-Resident Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation and implement effective interventions following incidents of resident-to-resident abuse. In one case, a resident verbally and physically abused another resident, and although they were initially separated and counseled, staff failed to maintain this separation during meals. Observations revealed that the two residents were seated together at the same dining table, contrary to the instructions given to staff. Interviews with staff indicated a lack of awareness regarding the need to keep these residents apart, and care plans were not updated to reflect the necessary changes to prevent further altercations. In another instance, a resident was moved to a new room to ensure timely medication delivery but was placed with a roommate with whom she did not get along. This led to frequent verbal altercations, particularly over the use of a TV remote control and the presence of an oxygen concentrator. The situation escalated to the point where one resident expressed a desire to give up rather than continue living in such conditions. Despite these ongoing issues, there was no evidence of a comprehensive investigation or effective interventions to address the conflicts between the roommates.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to update care plans in a timely manner for three residents involved in incidents of physical altercations, weight loss, and pain management. Resident #3 and #83 were involved in a resident-to-resident altercation that resulted in verbal and physical abuse. Despite the incident, Resident #83's care plan remained the original baseline care plan from admission and was not updated to address the altercation or the need to keep the residents separated in the dining room. Additionally, the care plan did not reflect that Resident #83 was on a psychotropic medication. Staff members interviewed were unaware of the altercation and the need for care plan updates. Resident #71's care plan was also not updated to reflect changes in dietary needs as recommended by a dietitian. The care plan inaccurately listed the resident's diet and did not include the dietitian's recommendation for a regular dysphasia mechanical soft diet and calorie-dense medication pass. Furthermore, the care plan contained multiple inaccuracies and incomplete sections, such as instructions for weight-bearing activities despite the resident being bed-bound, and unspecified details for blood pressure monitoring, medication side effects, and assistance required for toileting, transfers, and dressing.
Inadequate Discharge Planning and Medication Management
Penalty
Summary
The facility failed to adequately prepare and orient a resident for discharge, resulting in a deficiency. The discharge planning for the resident was incomplete, as evidenced by the lack of a home health referral being finalized prior to discharge. Staff member G indicated that discharge planning should have been completed before the day of discharge, but the social service staff responsible for this task was unavailable, and the Business Office Manager (BOM) was assisting with discharges. The resident was discharged without all necessary medications, specifically the fentanyl pain patches, which were discarded by two nurses instead of being sent home with the resident. The resident's discharge transition plan was incomplete, lacking documentation of the quantity of medications sent home and the next scheduled doses. Although a home health referral form was signed by the physician for post-discharge services, there was no indication that a home health agency was selected or contacted. The facility's discharge transition plan stated that arrangements for home health and other services would be made prior to discharge, but this was not fulfilled, leaving the resident without the necessary support and medications upon returning home.
Failure to Document Investigation of Resident-to-Resident Verbal Abuse
Penalty
Summary
The facility failed to provide evidence of reporting, investigation, and follow-up actions for allegations of resident-to-resident verbal abuse involving four residents. In the first incident, a verbal altercation occurred between two residents, where one resident threatened to kill the other, causing fear and necessitating the removal of the threatened resident from the shared room for safety. Despite the incident being reported to the State Survey Agency, the facility did not provide documentation of the investigation or findings by the end of the survey period. In the second incident, a verbal altercation occurred between two cognitively impaired residents, leading to their separation for safety. Although this incident was also reported to the State Survey Agency, the facility again failed to submit a report of findings for the investigation by the end of the survey period. During an interview, a staff member confirmed that the facility did not submit the required reports for these incidents.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain medication error rates below 5%, resulting in a calculated error rate of 15%. This deficiency affected two residents during medication administration. In one instance, a staff member administered an incorrect dose of Sodium Chloride to a resident. The physician's order was for a two-gram total dose, but the staff member initially dispensed only one gram. Upon questioning by the surveyor, the staff member corrected the error by administering an additional one-gram tablet. In another instance, a staff member failed to properly prime insulin pens before administering Insulin Glargine and Insulin Aspart to a resident. The facility's policy and manufacturer instructions require priming the insulin pen to ensure accurate dosing and remove air bubbles. The staff member did not perform this safety test, which is a critical step in the medication administration process. These actions and inactions contributed to the facility's failure to adhere to its medication administration policies, leading to the noted deficiency.
Dietary Staffing Shortage Leads to Delayed Meal Service
Penalty
Summary
The facility failed to adequately staff the dietary department, which led to delays in meal service and unmet resident preferences. Observations and interviews revealed that meals were consistently served late, with the noon meal on one occasion being served nearly an hour and a half past the scheduled time. Residents expressed dissatisfaction with the late meal service and the lack of attention to their food preferences. Staff interviews confirmed the shortage of dietary personnel, with only five staff members, including the manager, working in the department, despite the facility's assessment indicating a need for eight staff members. The deficiency affected all residents receiving meals from the dietary department, as evidenced by residents waiting in the dining room and in their rooms for meals to be served. Staff members reported assisting the dietary department as much as possible, but the shortage hindered their ability to maintain timely meal service and address resident preferences. The facility's documented mealtimes were not adhered to, and staff were unable to consistently gather and implement resident meal preferences due to the staffing shortfall.
Failure to Obtain Physician's Order for Self-Administration of Medication
Penalty
Summary
The facility failed to obtain a physician's order for medication self-administration before leaving medications at a resident's bedside. During an observation and interview, a staff member left a medicine cup containing two Cephalexin 500 mg capsules on a resident's bedside table for self-administration. When questioned, the staff member acknowledged the mistake and returned to observe the resident taking the medication. A review of the resident's medical record revealed the absence of a medication self-administration order.
Failure to Report Major Injury to State Survey Agency
Penalty
Summary
The facility failed to report a major injury of a resident to the State Survey Agency. The resident was found on the floor in her room by staff, complaining of pain, and was subsequently transported to the hospital. The resident, who had a low cognitive function and was not a reliable reporter, was diagnosed with a pelvic fracture, significant blood loss, and required intravenous fluids, blood transfusions, and evacuation of a large hematoma. The incident, which was unwitnessed and had no reliable source for the cause of the injury, was not reported as an unknown injury. A staff member acknowledged that the injury should have been reported but mistakenly believed it had already been submitted through the reporting portal.
Failure to Provide Baseline Care Plan Summaries
Penalty
Summary
The facility failed to provide residents or their representatives with a summary of their baseline care plan for three of the six residents sampled for baseline care planning. During interviews, a staff member admitted to not knowing the care plan for a resident who had not been in the facility long. Another resident expressed a desire for more therapy to gain strength for discharge but had not participated in a care plan discussion. A third resident acknowledged the benefits of therapy but had not been informed about their care plan. Staff member G mentioned that social services typically invite residents and representatives to care plan meetings and obtain signatures, but there were no signatures or evidence of baseline care plans in the residents' electronic health records (EHR). The absence of signatures and scanned documents in the EHR confirmed the deficiency in providing care plan summaries to the residents or their representatives.
Deficiency in Wound Care Management
Penalty
Summary
The facility failed to provide appropriate wound care for a resident with a Stage 2 pressure injury on the right lower shin. The physician's order required the dressing to be changed every other day with the application of alginate with silver or calcium alginate. However, during an observation, it was noted that the dressing lacked the prescribed materials, and the wound care was missed multiple times in May and June 2024. The facility's documentation did not consistently record the stage of the pressure injury, and there was no comprehensive review to determine if the wound was avoidable or unavoidable. Interviews with staff revealed a lack of audits and education to ensure proper wound care treatments were being performed according to physician orders. The facility also did not have the necessary committee meeting minutes or a comprehensive review of the resident's medical record to evaluate the avoidability of the pressure ulcer, as required by their Skin Integrity policy. This lack of documentation and oversight contributed to the deficiency in wound care management for the resident.
Improper Management of Resident Personal Food Storage
Penalty
Summary
The facility failed to ensure proper management of the communal resident personal food refrigerator and freezer. During an interview and observation, a staff member indicated uncertainty about who was responsible for monitoring the resident personal food refrigerator, including cleaning and temperature checks. The refrigerator and freezer lacked temperature logs, unlike other kitchen appliances in the same room. An observation revealed improperly stored food, such as a piece of fruit wrapped in a paper towel, not in a closed container, and undated. This lack of oversight led to confusion among staff about their responsibilities. A resident expressed frustration over the disposal of her groceries, which she purchased to address specific nutritional deficiencies. She reported that $50 worth of groceries were discarded because staff were unsure of the food's age. Despite attempts to resolve the issue with staff, the resident found no resolution. Interviews with other staff members revealed assumptions that kitchen staff were responsible for managing the resident personal refrigerator, but no one was certain of the assigned duties. A facility document outlined procedures for managing resident food, including temperature monitoring and food labeling, but these were not followed.
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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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