Mount Ascension Transitional Care Of Cascadia
Inspection history, citations, penalties and survey trends for this long-term care facility in Helena, Montana.
- Location
- 2475 Winne Ave, Helena, Montana 59601
- CMS Provider Number
- 275044
- Inspections on file
- 27
- Latest survey
- March 24, 2026
- Citations (last 12 mo.)
- 31
Citation history
Health deficiencies cited at Mount Ascension Transitional Care Of Cascadia during CMS and state inspections, most recent first.
A resident with dementia, cognitive decline, osteopenia, and a recent iliac fracture experienced three falls, including unwitnessed falls that resulted in bruising, a facial laceration, hematoma, skin tear, decreased LOC, and hospital transfer. Staff reported that IDT post-fall assessments were normally done within 24 hours to identify root causes and interventions, but acknowledged that this resident’s IDT reviews were not timely. The IDT post-fall note for the first fall, completed much later, identified issues with walker use and short-term memory and listed interventions such as increased visual checks, cueing, walker evaluation, and focused OT/PT, yet these interventions were not documented in the EHR or added to the care plan before the subsequent falls, contrary to the facility’s fall management policy.
The facility failed to implement an effective, data‑driven QAPI program when QAPI meetings were used mainly for informational departmental updates rather than systematic problem‑solving, root cause analysis, and follow‑up on identified concerns. Staff reported that PIPs existed in multiple departments, but meeting records showed that issues such as infection control, housekeeping/environmental problems, care plans, pain management, and skin/wound care were repeatedly identified without documented root cause analysis, measurable goals, timelines, or monitoring of interventions. Review of PIP and QAPI documentation showed a lack of defined action plans and evaluation of effectiveness, despite a written QAPI policy requiring regular analysis of quality deficiencies and structured performance improvement activities.
Two residents were found living in rooms that were not clean or well maintained, including dirty windows and windowsills, trash and debris on floors, damaged and unpainted walls, dust accumulation, an overflowing trash can, and discarded PPE on the floor. One resident reported that window and privacy curtains had not been washed in two years and that staff refused to remove them for cleaning, while another reported that no one had cleaned their room for at least two days. Staff interviews revealed inconsistent and conflicting descriptions of daily and deep cleaning practices, limited housekeeping coverage with one housekeeper per floor, uncertainty about whether curtains were removable, and a deep cleaning log whose reliability was questioned. Although facility documents referenced monthly complete room cleaning and a planned privacy curtain cleaning rotation, no documentation was produced to show that these practices were actually implemented.
Surveyors found that a resident on Enhanced Droplet Precautions for COVID-19 did not receive care consistent with posted PPE and hand hygiene requirements. Staff repeatedly entered and exited the resident’s room wearing only a face mask, without gowns, gloves, or eye protection, and did not perform hand hygiene between resident contacts. The PPE cart lacked gowns, no used gowns were found in the room trash, and the resident reported that staff did not always wear full isolation gear. Staff interviews revealed outdated or incomplete training on transmission-based precautions, misunderstanding of eye protection and Enhanced Barrier Precautions, and the facility could not provide documentation of current staff education despite having policies and CDC guidance requiring full PPE for COVID-19.
A resident with neuromuscular weakness, dysphagia, and speech impairments was found with seven capsules left in a medicine cup at the bedside, accessible without supervision. A staff member reported she had left the medications in the room while the resident was in the shower and acknowledged there was likely no MD order for self-administration. Record review confirmed there was no self-administration safety assessment, no physician order authorizing self-administration, and no swallow evaluation documenting the resident's ability to safely self-administer medications, while the failure was noted to place the resident at risk for choking, aspiration, and medication errors.
A resident was admitted with a physician’s order for PT to evaluate and treat, and the admission orders were signed off by nursing staff, but the order was never processed to the therapy department and no PT evaluation or treatment occurred during the stay. Staff interviews revealed that the usual process requires the admitting nurse to forward therapy orders to the therapy department so a PT can complete an initial assessment and PTAs can provide treatments, but in this case the order was either missed or not forwarded, leaving therapy staff unaware of it. Facility records, including the MDS and census reports, confirmed that the resident was never enrolled in therapy services despite the active order.
Dietary staff failed to follow sanitary food-handling and infection control practices during meal preparation and service. During a COVID-19 outbreak, two dietary staff worked in the food preparation area without infection control face masks. At breakfast, one staff member used the same gloved hands to handle trays, tray cards, food racks, and open juice glasses without changing gloves or performing hand hygiene, while another staff member handled sausages, muffins, eggs, cereal bowls, and plate surfaces with bare hands and no gloves or handwashing. At lunch, staff used bare hands to cut and plate pizza, scrape and arrange beans, place buns, and cut and plate sandwiches. A staff member reported that kitchen staff should never touch food with bare hands, confirming that these observed practices did not follow expected infection control standards.
A resident was transferred to a hospital and did not return, yet the facility failed to provide or document the required written transfer and bed-hold notices. Staff reported that residents transferring out are supposed to sign transfer and bed-hold forms, with nurses completing and assisting with signatures as needed, but could not confirm that this occurred for the resident involved. Review of facility policies showed that written notices explaining the reason, effective date, and destination of a transfer, as well as bed-hold notices given in advance and at the time of transfer or within 24 hours for emergencies, must be provided and kept in the clinical record; however, no such notices were found for this resident, and a facility document indicated there was no bed hold for the transfer.
A resident who was dependent on staff for bathing and preferred showers twice weekly did not consistently receive scheduled showers, with records showing multiple missed shower days and extended intervals between showers over a three‑month period. CNAs reported using a shower schedule and a list at the nurse’s station, re‑approaching residents after refusals, and documenting refusals on shower refusal forms, yet only one refusal form was found in the notebook. The facility’s ADL policy required assistance with hygiene based on individual needs and preferences and documentation of ADL assistance and resident response, but the resident’s documented shower frequency did not match the stated preference and care plan.
A resident receiving chemotherapy for metastatic cancer tested positive for COVID-19 and was prescribed Molnupiravir, an oral antiviral authorized for high-risk adults with mild-to-moderate COVID-19. Nursing notes show the drug was expected from the pharmacy the next morning but had still not arrived by later that day, and it was not administered until that night when it finally came from an out-of-state pharmacy, resulting in a two-day delay in treatment. A staff member reported that medications were sometimes not delivered timely, that they relied on an out-of-state pharmacy to restock despite having an Omnicell and access to a local satellite pharmacy, and that this case exemplified failure to obtain COVID-19 treatment medication promptly, contrary to the facility’s pharmacy services policy requiring timely provision of routine and emergency medications 24/7.
A resident with an ostomy and recent surgical site became anxious and repeatedly dug at the stoma and wound, causing bleeding. After administering PRN lorazepam and morphine without resolving the behavior, an agency nurse, who had not received facility-specific abuse and restraint training, attempted to wrap the resident’s hands with washcloths and pillowcases to stop her from digging. Another staff member intervened, stopped the wrapping, and removed the materials, but during the episode the resident bit at the wrapped hand and cracked a tooth. Review of personnel files showed that required abuse and restraint training had not been completed before these agency staff began providing care, leading to a deficiency for improper use of physical restraints.
A resident with schizophrenia, depression, and moderate cognitive impairment, identified as an elopement risk, was taken to a dental appointment with clear written instructions that staff must stay with him. The transporting staff member, though aware of the elopement risk, left the resident unattended once he was taken to the exam room, and the resident subsequently left the office alone, took a taxi, and went to a relative’s home about two miles away, with his whereabouts unknown for about an hour. After the event, facility staff completed only a basic incident report and did not conduct or document an IDT review, after-action/post-elopement evaluation, root cause analysis, or corrective actions, despite an existing elopement policy requiring such investigation and documentation.
A resident with mental health issues, impaired decision-making, and a documented elopement risk repeatedly expressed a desire to leave, including plans to travel out of state, yet the facility did not individualize the care plan to include family-discussed interventions such as supervised walks, supervised medical appointments, or measures tied to medication refusal and increased elopement risk. Behavior monitoring for wandering and exit-seeking was not implemented despite documented nighttime pacing and an attempted self-discharge. During transport to a dental appointment, a staff member who knew the resident was an elopement risk left the resident unsupervised at the clinic, contrary to expectations noted on the appointment schedule, allowing the resident to leave by taxi to a relative’s home. The facility did not complete a documented IDT after-action investigation, did not promptly perform a post-elopement evaluation, and only maintained largely generic elopement care plan interventions after the resident’s return.
The facility did not follow its grievance policy, resulting in multiple unresolved complaints from residents and their representatives. Grievances about care issues, such as delayed call light response, improper repositioning for pressure ulcer prevention, and staff-inflicted injuries, were not investigated or documented. Staff interviews confirmed that grievances were often ignored or deprioritized, and required follow-up steps were not completed, leaving residents without resolution or communication regarding their concerns.
The facility did not report multiple allegations of abuse and neglect to the State Survey Agency as required. A resident complained of not being repositioned and missed care, while two others reported being hurt by staff during care and transfers. These incidents were documented but not reported or investigated according to policy.
The facility did not investigate or report multiple complaints of potential abuse and neglect, including two residents who reported being hurt by staff during care and a resident with pressure ulcers who was not repositioned as required. Staff confirmed that these incidents were not reported or investigated according to facility policy.
The facility failed to maintain RN coverage for at least eight consecutive hours daily, as required. Interviews and record reviews showed that on several occasions, no RN was scheduled, leading to concerns from residents about staffing levels. Staff attempted to find replacements using a program or management staff. Concerns were also raised about the accuracy of PBJ reporting.
The facility failed to implement enhanced barrier precautions (EBP) in the 100 north hall, as staff did not use appropriate PPE when caring for residents with catheters, tubes, or wounds. Observations showed a lack of EBP signage and staff awareness, leading to inadequate infection control practices.
The facility's antibiotic stewardship program was found deficient due to inadequate infection surveillance and monitoring of antibiotic use. A staff member reported a lack of support and adherence to McGreer's criteria by healthcare providers. The infection control log showed several urinary tract infections treated with antibiotics without proper culture and sensitivity testing, and the facility struggled to track organisms for residents on antibiotics from hospitals.
The facility failed to ensure proper screening and documentation for influenza, pneumonia, and COVID-19 immunizations for residents. Three residents were not screened for pneumococcal vaccines, and there was no documentation of either vaccine administration or signed declinations. One resident had not received an updated pneumococcal vaccine since 2000, while two others had no records of receiving or declining the vaccine. A staff member was unaware of her responsibility for immunizations and only ordered the vaccines after the surveyor's request.
A resident requested to be sent to the hospital due to feeling unwell and low oxygen levels, but the facility staff did not arrange the transfer. Instead, a non-facility caregiver called an ambulance, leading to the resident's transport to the hospital. This incident highlights a failure to respect the resident's rights to self-determination and participation in their treatment.
A resident's allegation of neglect was not reported to the State Survey Agency within the required 24-hour period. The incident involved the resident feeling unwell and requesting hospital transfer, which was delayed by staff. Despite internal reminders, the report was submitted late after an anonymous complaint was received.
A resident's request to go to the hospital due to feeling unwell was not promptly addressed by facility staff, despite critically low oxygen saturation levels. The resident's non-facility caregiver eventually called an ambulance, leading to the resident's transfer to a hospital. The facility failed to document follow-up assessments or actions taken, violating their documentation policy.
The facility failed to ensure physician orders for oxygen therapy were present in the EHR for two residents and did not consistently label oxygen supplies with cleaning or change dates for five residents. Observations revealed that residents' oxygen equipment was not labeled, and staff were uncertain about the necessity of physician orders for oxygen therapy.
A facility failed to implement a resident's dietary preferences and address therapeutic diet changes over the weekend. The resident, who had difficulty swallowing dry meats, did not receive meals with gravy as preferred, and diet changes were not communicated timely, leading to inappropriate meal preparation. Staff acknowledged discrepancies in following the diet order, highlighting a lack of consistent processes for weekend diet changes.
The facility failed to maintain water temperatures within CDC guidelines to prevent Legionella growth, conducting bi-weekly instead of weekly checks. Residents reported not seeing temperature checks, and observations noted dirty sinks and toilets. Staff lacked specific education on Legionella prevention, with no documentation provided. The infection preventionist did not intervene when a resident was diagnosed with Legionella, and preventative measures were not increased.
A resident in an LTC facility suffered a fractured hip due to inadequate assistance during a transfer, requiring surgery. The facility also failed to maintain a smoke-free environment, with one resident using a marijuana vape pen in bed and two others smoking on the premises, despite policies prohibiting such activities. Staff were aware of these issues but did not enforce the facility's policies, creating safety hazards.
The facility failed to conduct and document required care conferences, excluding residents and their representatives from participating in care planning. Interviews revealed that residents and their representatives were not invited to attend, and EHR reviews showed missing documentation for several MDS periods. Staff acknowledged the backlog and planned to address it, but the facility did not provide a policy for care conferences.
The facility failed to inform residents about the grievance process and how to file grievances, as multiple residents were unaware of grievance forms or the process. Staff interviews revealed inadequate handling and documentation of grievances, with some staff instructed not to file grievances or provide the ombudsman's contact information. The facility's grievance logs showed minimal entries, despite numerous complaints raised in resident council meetings, and staff were unable to locate documentation for these grievances.
The facility failed to report abuse allegations and investigation results to the State Survey Agency and Adult Protective Services. A resident reported verbal and physical abuse by a CNA, but the staff dismissed the claims without investigation. Another resident's fall resulting in rib fractures was not reported within the required timeframe. These actions violate the facility's policy on reporting abuse and serious injuries.
A facility failed to investigate and report alleged abuse by a CNA towards a resident, who claimed verbal abuse and threats from another resident. The facility did not offer counseling or document the allegations, and staff dismissed the incident as 'old news'. The facility's policy on reporting such incidents was not followed.
Two residents in the facility developed and experienced worsening pressure ulcers due to inadequate care. One resident's sacral ulcer progressed from Stage III to Stage IV, with multiple missed dressing changes and pain reported. Another resident developed a Stage III ulcer from a skin tear caused by improper use of a Hoyer lift sling. The facility failed to implement effective pressure ulcer prevention strategies and did not follow physician orders for wound care.
A resident at high risk for pressure ulcers developed a Stage IV ulcer due to the facility's failure to follow wound care protocols. Despite staff awareness of necessary interventions, multiple dressing changes were missed, and the resident arrived at the wound clinic without dressings on two occasions.
The facility failed to develop comprehensive care plans for two residents, leading to deficiencies in care. One resident developed a Stage III pressure ulcer due to improper handling with a mechanical lift, and the care plan lacked interventions for ulcer prevention and treatment. Another resident experienced pain during wound dressing changes, but the care plan did not include specific pain management interventions, despite the availability of pain medication.
A facility failed to provide adequate pain management for a resident with a Stage IV ulcer during dressing changes. Despite orders for pre-appointment pain medication, records were unclear if medication was given before dressing changes. Staff interviews indicated pain should be reported and managed, but the care plan lacked specific interventions for pain related to the wound.
Failure to Complete Timely IDT Post-Fall Assessment and Implement Fall-Prevention Interventions
Penalty
Summary
Surveyors identified a failure by the facility to ensure timely, comprehensive IDT post-fall assessments, root cause analyses, and implementation and documentation of fall-prevention interventions for a resident with multiple falls. The resident was admitted after a hospitalization for a right iliac crest fracture and had diagnoses including osteopenia, degenerative changes, altered mental status, dementia, cognitive decline, weight loss, and lethargy, with documentation that her cognitive decline had progressed rapidly over the prior month. Nursing notes showed the resident experienced three falls: the first occurred when she attempted to park her wheeled walker without locking the brakes and fell on her right knee and hip; the second was an unwitnessed fall resulting in bruising to the right elbow and hip; and the third was an unwitnessed fall resulting in a facial laceration, hematoma to the left brow, a skin tear to the left elbow, decreased level of consciousness, and transfer to the hospital. During this period, the resident was also placed on palliative care and tested positive for COVID-19. Interviews with staff revealed that IDT post-fall assessments were typically completed within 24 hours and used to identify root causes and interventions, with care plans updated as needed, but staff acknowledged that IDT meetings for this resident did not occur in a timely manner. The IDT post-fall note for the first fall, which was not dated until nearly two weeks later, identified root causes related to improper walker use and short-term memory deficits, and listed interventions such as more frequent visual checks, consistent cueing for safe walker handling, evaluation of the walker, and continued OT/PT with a focus on fall prevention. However, review of the electronic health record and the resident’s care plan showed no evidence that these interventions were implemented or added to the care plan before the resident’s subsequent falls and hospitalization. This was inconsistent with the facility’s own Fall Response & Management policy, which required evaluation of causal factors after a fall, review and updating of the care plan with individualized measures, and IDT review and placement of interventions following fall incidents.
Failure to Implement Effective, Data‑Driven QAPI Program
Penalty
Summary
The facility failed to develop and implement an effective, comprehensive, data‑driven QAPI program. Interviews revealed that department managers used a shared PowerPoint to present departmental updates and Performance Improvement Projects (PIPs) at quarterly QAPI meetings, and that each department had multiple PIPs in the past year. However, one staff member reported that QAPI meetings were primarily informational, focused on reviewing departmental activities rather than problem‑solving or process improvement, and did not consistently include follow‑up on previously identified concerns. Another staff member stated that the QAPI committee "definitely needs to be more than it has been" and that meetings should occur more frequently to address ongoing system failures and monitor progress of PIPs. Review of quarterly QAPI meeting documentation for 2025 showed that multiple quality concerns were identified, including infection control practices, housekeeping/environmental issues, care plans, pain management, and skin and wound issues, but the records lacked evidence of root cause analysis, clearly defined action plans, or monitoring for effectiveness and sustained improvement. Review of PIP documentation for 2025 showed that multiple projects were initiated without measurable goals, timelines for completion, or evidence of ongoing evaluation of interventions, and several issues were repeatedly identified across multiple meetings without documented resolution or progress. These practices did not align with the facility’s written QAPI policy, which required at least monthly meetings to identify performance improvement opportunities, establish goals and performance indicators, systematically analyze underlying causes, prioritize and develop action plans, implement process improvement strategies, and evaluate effectiveness and sustained results.
Failure to Maintain Clean, Sanitary, and Homelike Resident Rooms
Penalty
Summary
The deficiency involves the facility’s failure to provide a clean, sanitary, and homelike environment for residents, as evidenced by conditions in two sampled residents’ rooms and inconsistent housekeeping practices. In one resident’s room, surveyors observed soiled window surfaces, visibly dirty windowsills, trash items (a paper wrapper and medicine cup) on the floor near the trash can, and wall surfaces with holes, cracks, and missing paint. The resident reported living in the facility for two years and stated that neither the window curtains nor the privacy curtains had been washed during that time. The resident further stated that when they asked housekeepers about cleaning the curtains, they were told the curtains could not be taken down due to privacy concerns, and described the curtains as being touched by everyone and not cleaned well. Another resident’s room was observed not to have received basic daily cleaning, with dust and debris under the bed and heat register, dust on the dresser, a crumpled napkin on the floor near the bed, an overflowing trash can, and a discarded glove and gown tie on the floor near the trash can. This resident stated that no one had come in to clean their room the previous day or the day of the observation. These observations showed that routine cleaning tasks, such as trash removal, dusting, and floor cleaning, were not consistently performed in resident rooms. Interviews with staff revealed conflicting and unclear information about the frequency and scope of daily and deep cleaning. One staff member stated that no deep cleaning was being completed, that there was only one housekeeper per floor responsible for many residents, and that CNAs cleaned as needed after housekeeping left for the day. Another staff member initially stated that every room was deep cleaned daily, then clarified that downstairs rooms were deep cleaned daily and upstairs rooms weekly, and later stated the facility was working on a monthly deep cleaning schedule. This staff member also reported not knowing if window and privacy curtains were removable. Another staff member stated that two rooms per floor were deep cleaned each day and questioned the reliability of the deep clean log, noting that “anyone can check something off.” Review of QAPI minutes showed a plan to start a privacy curtain cleaning rotation, but no documentation of such a rotation was provided, and the facility’s own “Complete Room Cleaning” document referenced monthly discharge-level cleaning and checking curtains without evidence this was carried out as described.
Failure to Implement Enhanced Droplet Precautions and PPE for COVID-19
Penalty
Summary
The deficiency involves the facility’s failure to implement appropriate infection prevention and control practices, including hand hygiene, transmission-based precautions, and use of PPE, for a resident on Enhanced Droplet Precautions for COVID-19. Surveyors observed signage at the public entrance indicating active COVID-19 cases in the building and a sign on the resident’s door requiring an N95 mask, gown, gloves, and eye protection. A PPE cart outside the room contained eye protection, masks, and gloves, but no isolation gowns, and no PPE was observed inside the room or in the trash receptacle. On multiple occasions, staff entered and exited the resident’s room wearing only a face mask, without gowns, gloves, or eye protection, and no hand hygiene was observed before or after room entry. One staff member entered the resident’s room to deliver medications while the resident was in the shower, then immediately went into another resident’s room wearing the same mask and without performing hand hygiene. The resident reported being in isolation for 14 days after testing positive for COVID-19 and stated that staff did not always wear gowns or all the required isolation gear, suggesting inconsistent adherence to the posted precautions. Staff interviews confirmed lapses in practice and knowledge: one staff member acknowledged that PPE should have been worn but was not, another stated it had been quite some time since they had training, and a contracted staff member reported not receiving updated training on transmission-based precautions from either the agency since 2023 or the facility. This contracted staff member also had an incorrect understanding of when eye protection was required for Enhanced Droplet Precautions and did not understand when Enhanced Barrier Precautions would be used. The facility was unable to provide requested documentation of staff education on Enhanced Droplet and Enhanced Barrier Precautions by the end of the survey, despite having a written policy dated 9/13/25 requiring N95 or higher respirator, gown, gloves, and eye protection for conditions such as COVID-19, and CDC guidance specifying hand hygiene and full PPE for Enhanced Droplet Precautions.
Medications Left at Bedside Without Order or Safety Assessment
Penalty
Summary
The deficiency involves staff leaving medications at a resident's bedside for unsupervised self-administration without a physician order or completed safety assessment. During an observation, a resident with neuromuscular spasticity of both upper extremities, weak vocal quality, slowed speech, and generalized neuromuscular weakness was seen lying in a recliner with seven assorted capsules in a medicine cup on a table within reach. The medications were accessible without supervision. A staff member later stated she had entered the resident's room earlier and left the medications at the bedside while the resident was in the shower, and acknowledged the resident probably did not have a physician's order for self-administration of medications. Further review of the resident's electronic health record showed diagnoses of oropharyngeal dysphagia, dysarthria, anarthria, and conversion disorder with motor symptoms. The record contained no self-administration safety assessment or physician order authorizing self-administration of medications. A speech therapy note indicated the resident was permitted to have bread and was on a regular diet with a preference for rye bread, but there were no additional speech therapy notes or swallow evaluations documenting the resident's ability to safely swallow or self-administer medications. The facility did not provide any documentation of a medication self-administration safety assessment, speech therapy evaluation supporting safe self-administration, or a physician order for self-administration by the end of the survey, and the failure was noted to place the resident at risk for choking, aspiration, and medication errors.
Failure to Implement Physician-Ordered Physical Therapy Services
Penalty
Summary
The deficiency involves the facility’s failure to ensure that physician-ordered physical therapy services were implemented for one resident in accordance with professional standards of quality. Admission orders dated 12/23/25 included a physician’s order for physical therapy to evaluate and treat, and these admission orders were signed off by a nurse (NF2) on 1/1/26. However, review of the resident’s admission MDS with an ARD of 12/29/25 showed no therapy services documented in Section O0390, and a Census Details Report dated 3/23/26 confirmed the resident was never enrolled in therapy services at any time during the stay. The resident was later transferred to an assisted living facility on 2/10/26, per the request of NF1. Interviews with staff revealed that the facility’s process for initiating therapy orders was not followed or failed at some point. Staff member D explained that when therapy orders are included in admission orders, the admitting nurse is responsible for forwarding a copy to the therapy department so that the physical therapist can complete the initial assessment, and stated that the resident’s initial therapy order may have been missed or not forwarded, leaving therapy staff unaware of the order. Staff member H stated that when a new therapy order is received, a PT evaluation is typically completed within a couple of days and treatments are then carried out by PT assistants, but acknowledged that this resident did not receive the ordered services and could not explain how this occurred. NF1 confirmed by phone that the resident was admitted with therapy ordered but did not receive therapy during the stay. Reference to National Council of State Boards of Nursing standards indicated that nurses are responsible for implementing patient care orders unless there is a reason to question them.
Unsanitary Food Handling and Infection Control Failures in Dietary Services
Penalty
Summary
The deficiency involves failure of kitchen staff to handle and serve food in a clean and sanitary manner in accordance with professional standards and infection control practices. During a COVID-19 outbreak at the facility, two dietary staff members were observed working in the food preparation area without wearing infection control face masks. During breakfast meal service, one staff member assembling resident breakfast trays wore gloves but used the same gloved hands to handle trays, tray cards, food racks, and then cupped her hand over open juice glasses without changing gloves or washing/sanitizing her hands, moving between clean and contaminated tasks. Another staff member was not wearing gloves and used bare hands to grab link sausages, cut them, and place them on plates, as well as to grab muffins, move eggs around on plates, and touch the inside of cereal bowls and plate surfaces where food would be placed, without handwashing, sanitizing, or donning gloves. During an interview, another staff member stated that kitchen staff should never touch food with their bare hands, indicating that the observed practices were inconsistent with expected procedures. During lunch service, one staff member was observed cutting pizza and placing it on plates with bare hands, scraping beans from a serving spoon and moving them around on plates with bare hands, and placing buns on plates with bare hands. Another staff member cut a sandwich and placed it onto a resident’s plate with bare hands. These observations showed repeated failures by multiple dietary staff members to follow infection control precautions and sanitary food-handling practices during meal preparation and service for residents receiving food from the kitchen.
Failure to Provide Required Written Transfer and Bed-Hold Notices
Penalty
Summary
The facility failed to provide a written notice of the reason for a facility-initiated transfer or bed hold to a resident or the resident's representative. One resident was discharged from the facility to a local hospital, and review of the electronic medical record showed a discharge date but no transfer or bed hold notices. The resident did not return to the facility following this transfer. When surveyors requested the transfer and bed hold notice for this resident, the facility produced a document stating there was no bed hold present for the transfer on that date. During interviews, one staff member stated that residents who transferred to the hospital for urgent evaluation would sign a bed hold and transfer notice form, and that the nurse transferring the resident would complete it, but she did not know if a form was filled out for this resident. Another staff member stated that residents who transferred from the facility signed a transfer notice and a bed hold notice form, and that nurses would assist residents to sign if they were unable. Review of facility policies showed that written discharge or transfer notices, including the reason, effective date, and location, must be provided and a copy maintained in the clinical record, and that bed-hold notices must be provided in writing in advance and again at the time of transfer or within 24 hours for emergency transfers. These required notices and documentation were not present in the resident's record.
Failure to Provide Scheduled Bathing Assistance per Resident Preference and Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to provide assistance with activities of daily living (ADLs), specifically bathing, to a resident who was dependent on staff for bathing and had a stated preference for showers twice weekly on Tuesdays and Fridays. The resident reported very rarely receiving two showers per week and stated she did not feel clean due to the lack of showers. Review of the resident’s care plan dated 1/21/26 showed she was dependent on staff for bathing with assistance of one staff member. Review of bathing records from 12/1/25 through 2/26/26 showed the resident was scheduled for showers twice weekly but did not receive scheduled showers on multiple dates, resulting in 17 showers out of 24 opportunities over three months. The electronic medical record showed the resident went without a shower for more than six days on four occasions and once for 13 days between showers, supporting the resident’s claim of not receiving the preferred two showers per week. Staff interviews revealed that CNAs relied on shower schedules and a list at the nurse’s station to determine which residents were to receive showers, and that refusals were to be re-approached and, if persistent, documented on a shower refusal form with the resident’s signature. One staff member stated she was unsure if residents scheduled for evening showers had been completed and noted that residents scheduled for evening showers often requested showers the following day. Another staff member stated that if a resident refused a shower, a different CNA would offer it, and if refusal continued, a refusal sheet would be completed and signed by the resident. When the shower refusal notebook at the nursing station was checked, only one refusal form was present. The facility’s ADL policy dated 9/8/25 stated that residents receive assistance with ADLs, including hygiene and bathing, based on individual needs, preferences, and care plan goals, and that ADL assistance and resident response are documented in the medical record, but the documented shower frequency for this resident did not align with her care plan and stated preferences.
Delayed Delivery of Antiviral Medication for High-Risk COVID-19 Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide a prescribed antiviral medication in a timely manner to a resident with COVID-19. The resident had a chronic illness and was receiving chemotherapy for metastatic cancer. After the resident tested positive for COVID-19, the physician ordered Molnupiravir, an oral antiviral medication authorized for adults with mild-to-moderate COVID-19 who are at high risk for progression to severe disease. Nursing progress notes show that on the day after the positive test, staff documented that Molnupiravir was supposed to be delivered that morning, but by mid-afternoon it had not arrived from the pharmacy. Later that night, nursing documentation shows that Molnupiravir was finally administered when it arrived from the pharmacy, resulting in a two-day delay in starting treatment for an acute illness. During an interview, a staff member reported that prescription medications were delivered from an out-of-state pharmacy and that there were times when medications were not delivered timely. The staff member stated they had received verbal confirmation that the medication for this resident had been received, but when they returned to work the next day, it had not been delivered. The staff member also explained that although the facility had an Omnicell and access to a local satellite pharmacy, they were dependent on the pharmacy to restock medications, and this resident’s case was cited as an example of not receiving COVID-19 treatment medication in a timely manner. The facility’s pharmacy services policy required collaboration with the pharmacy to ensure medications are requested, received, and administered in a timely manner and that routine and emergency pharmacy services are available 24/7.
Improper Use of Hand Restraints by Untrained Staff Resulting in Resident Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure that staff received facility-specific restraint and abuse prevention training prior to providing resident care, resulting in the use of an unauthorized physical restraint on a resident. A staff member (Staff D) observed Resident #3, who had an ostomy and a surgical wound on the hip, becoming very anxious and agitated and digging at her surgical site and stoma to the point of causing bleeding. After administering PRN lorazepam and morphine and reassessing the resident 15–20 minutes later, Staff D noted that the resident continued to dig at her surgical site and stoma and became further concerned for her safety. At that point, Staff D attempted to protect the resident by wrapping washcloths and pillowcases around the resident’s hands to prevent her from continuing to dig at her ostomy site. One hand was already wrapped when another staff member (Staff E) entered the room and observed Staff D attempting to wrap the resident’s other hand. Staff E immediately stopped the process, informed Staff D that what he was doing could be considered a restraint and was not allowed in the LTC setting, and removed the washcloths from the resident’s hand. During this episode, the resident bit at her wrapped left hand and cracked one of her teeth. The facility’s investigation confirmed that this was an incident in which a well-intentioned staff member, attempting to protect the resident from self-harm, implemented an intervention that was not appropriate for the setting and constituted a physical restraint. Review of personnel files for Staff D and other agency staff showed that restraint and abuse prevention training had not been completed by the facility prior to them providing resident care and prior to the incident. This lack of required training and the subsequent use of an improvised hand restraint on the resident led to the identified deficiency related to improper use of physical restraints.
Failure to Investigate and Address Elopement After Unsupervised Off-Site Appointment
Penalty
Summary
The deficiency involves the facility’s failure to complete a thorough investigation and take corrective action after a resident with a known elopement risk left supervision during an off-site dental appointment. The resident had diagnoses including schizophrenia/schizoaffective disorder, major depressive disorder, and moderate cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 12. According to the resident’s family member, the resident experienced hallucinations and exhibited poor and impulsive decision-making, making him vulnerable when left unattended. The facility’s appointment calendar for the dental visit specifically documented in capital letters that staff were to stay with the resident due to elopement risk and noted that his sister would arrive shortly after the scheduled appointment time. On the day of the dental appointment, a staff member transported the resident and was aware that the resident was not to be left unsupervised. The staff member waited until the resident was escorted to the exam room, then left the office to pick up paperwork from another facility, believing the resident would be safe while with the dentist. When the staff member returned, dental staff reported that the resident had already left. The resident’s whereabouts were unknown for approximately one hour, during which time he left the dental office alone, obtained a taxi, and traveled to a relative’s home approximately two miles away. The facility-reported incident documented that the resident refused to return to the facility and expressed a desire to live on his own and to travel out of state to visit friends. Following the elopement event, facility leadership acknowledged that no Interdisciplinary Team (IDT) review, after-action plan, or full investigation was completed regarding the resident’s elopement from the dental office. Staff stated that aside from the facility-reported incident form, they did not document the sequence of events from the time the resident was left unsupervised at the dental visit to the time he was located, nor did they determine or document corrective actions. This lack of investigation and documentation occurred despite the facility’s written Elopement policy, which required the IDT to investigate elopement incidents, identify contributing factors and root causes, and document findings and recommendations in the medical record with updates to the plan of care as indicated.
Failure to Individualize Elopement Care Plan and Provide Supervision During Off-Site Appointment
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident at known risk for elopement had adequate, individualized care plan interventions and supervision to prevent elopement. The resident had a history of mental health problems, impaired decision-making, and expressed desires to leave the facility, including plans to travel to another state to visit friends who were deceased or incarcerated. An elopement/wandering risk evaluation completed in early September identified the resident as an elopement risk and recommended increased monitoring, staff notification, and care plan updates. The resident’s sister (POA) reported that the resident did better when compliant with medications and became more irrational and impulsive when he stopped taking them. She also reported, on multiple occasions, that the resident expressed anger about being placed in the facility and a desire to leave, including to visit friends in another state. Despite these known risks and repeated verbalizations of intent to leave, the resident’s care plan did not incorporate specific interventions discussed with the family, such as supervised walks, supervised medical appointments when the sister could not attend, or interventions tied to medication refusal and increased elopement risk. The care plan contained general wandering/elopement interventions (e.g., redirection, hourly monitoring, diversional activities, elopement risk assessments) but did not address the resident’s specific behaviors, his stated plan to travel out of state, or his sleep disturbances and nighttime pacing. Nursing progress notes documented the sister’s concerns about the resident’s ongoing desire to elope and resentment about being in the facility, as well as an incident where the resident attempted to sign himself out and leave the facility, but there was no corresponding update to the care plan to reflect these escalating behaviors. The facility also failed to provide routine behavioral monitoring for the resident’s elopement-related behaviors and did not have behavior monitoring orders in place for wandering or exit-seeking from September through mid-December, despite documentation of nighttime pacing and lack of sleep. On the day of the elopement from a dental appointment, the transport staff member was aware the resident was an elopement risk and that staff were expected to stay with such residents during outside appointments. The appointment calendar specifically noted that staff were to stay with the resident due to elopement risk. Nonetheless, the staff member left the resident unsupervised at the dental office to run an errand, and during this unsupervised period the resident left the office, called a taxi, and went to a relative’s home. The facility then treated the situation as if the resident were leaving against medical advice and did not complete an interdisciplinary after-action investigation or documented root cause analysis of the elopement. An updated elopement evaluation was not completed until four days after the resident’s return, and the post-readmission care plan remained largely generic, without incorporating the family-agreed stipulations or individualized interventions to prevent recurrence. The facility’s own policies required an elopement/wandering evaluation to be completed post-elopement, an IDT investigation with root cause analysis, and care plan updates after any incident involving unsafe wandering or elopement. Staff interviews confirmed that the expectation was to review and revise the care plan after an elopement and to conduct behavior monitoring for residents identified as elopement risks. However, for this resident, there was no documented IDT after-action plan, no timely post-elopement evaluation, and no documented care plan revisions that reflected the specific risks and conditions that had been identified by staff and family prior to and following the elopement. These omissions, combined with the failure to maintain supervision during transport to a medical appointment, led to the resident leaving unsupervised and constituted the cited deficiency in accident hazard prevention and supervision. The facility’s failure to address these concerns placed this resident at a continued risk of elopement and/or harm.
Failure to Investigate and Resolve Resident Grievances
Penalty
Summary
The facility failed to uphold and operationalize its grievance policy, resulting in multiple grievances from residents and their representatives not being investigated or resolved. Documentation was incomplete or missing for grievances, with no evidence of follow-up, investigation, or communication of outcomes to the complainants. Staff interviews revealed that grievances were often deprioritized, and some staff only investigated complaints if they suspected abuse, otherwise taking no further action. Grievances submitted through resident council meetings and grievance boxes were not consistently included in the official grievance binder, and many lacked required documentation such as investigation steps, findings, or resolution status. Several residents reported ongoing care concerns, including not being repositioned as required for pressure ulcer prevention, delayed response to call lights, and improper medication administration. Residents and staff described repeated complaints about care issues such as lack of showers, long call light response times, and being left wet overnight, with no evidence that these concerns were addressed. Some grievances involved allegations of staff causing injury during care, but these were not investigated as potential abuse or neglect, nor were they reported as required by facility policy. Facility records and interviews indicated a systemic breakdown in the grievance process, with staff acknowledging that grievances were not prioritized and often ignored. The facility's own policy required acknowledgment, investigation, and documentation of all grievances, including reporting of alleged abuse or neglect, but these steps were not followed. As a result, residents and their representatives did not receive responses or resolutions to their concerns, and there was no documentation of corrective actions or communication regarding the outcomes of their grievances.
Failure to Report Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to identify and report accusations of abuse and/or neglect by staff to the State Survey Agency for three of seven sampled residents. In one case, a resident complained about not being repositioned throughout the night, and a family member raised concerns regarding missed medication administration and catheter care. These concerns were documented in progress and physician notes, but staff confirmed that no report was made to the State Survey Agency regarding these allegations of neglect. Additionally, grievances were filed by two other residents: one reported being hurt by a night CNA during care, and another, who was being treated for a recently fractured arm, reported pain when a staff member pulled his arm during a transfer. Both of these allegations, which could indicate potential abuse or neglect, were not reported to the State Survey Agency as required by facility policy. Staff interviews confirmed that these accusations should have been reported and investigated, but this did not occur.
Failure to Investigate and Report Alleged Abuse and Neglect
Penalty
Summary
The facility failed to thoroughly investigate and report alleged violations of abuse or neglect involving three residents. One resident reported being hurt by a staff member during care, and another resident with a fractured arm complained that a staff member hurt his arm during a transfer. Grievance records for both residents did not show evidence that these events were investigated or reported to the State Survey Agency as potential abuse or neglect. Additionally, a third resident with pressure ulcers and a care plan requiring frequent repositioning complained of not being repositioned all night. This resident's family also raised concerns about missed administration of prescribed vaginal cream and lack of catheter care, despite physician orders for both interventions. Interviews with staff confirmed that these complaints and allegations were not reported to the State Survey Agency or investigated as required. The facility's policy mandates review and investigation of grievances, complaints, and allegations of abuse or neglect, but records and staff interviews indicated that these procedures were not followed for the incidents involving the three residents.
Failure to Maintain RN Coverage
Penalty
Summary
The facility failed to have a registered nurse (RN) on duty for at least eight consecutive hours a day, seven days a week, as required. This deficiency was identified through interviews and record reviews, revealing that on multiple occasions from July to October 2024, there was no RN scheduled for the required hours. Residents expressed concerns about the staffing levels, noting that it was sometimes difficult to be seen by a nurse due to their busyness. Staff interviews indicated that when an RN was not scheduled, the facility attempted to find replacements using a program called Clipboard or by having management staff cover the floor. Additionally, there were concerns about the accuracy of PBJ reporting, which is managed by a corporate person outside the facility.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure staff practiced appropriate use of personal protective equipment (PPE) during the care of residents on enhanced barrier precautions (EBP) in the 100 north hall. Observations revealed that no EBP signs were posted, and staff did not use gowns or gloves when providing care to residents with catheters, cholecystostomy tubes, or surgical wound dressings. Staff members were observed assisting residents with personal care and transfers without the necessary PPE, despite the presence of conditions that required EBP. Interviews with staff indicated a lack of awareness and communication regarding EBP requirements. Staff member I stated that there were no signs to designate the need for PPE, and the CNA staff did not share EBP statuses in their shift reports. Staff member D acknowledged that EBP would be required for residents with catheters, wounds, or other tubes, but staff member C was unaware of what EBP entailed. The facility's Transmission-Based Precautions Conventional Plan outlined the need for targeted gown and glove use during high-contact activities, but this was not being implemented effectively.
Deficient Antibiotic Stewardship Program
Penalty
Summary
The facility failed to maintain an effective antibiotic stewardship program, which is crucial for monitoring antibiotic use and infection surveillance. During an interview, a staff member expressed a lack of support in her role since November 2024, indicating that some healthcare providers in the facility do not adhere to McGreer's criteria when prescribing antibiotics. Instead, antibiotics were sometimes prescribed based on behavior or symptoms, and the staff member felt unable to influence the prescribing practices of doctors. This lack of adherence to established criteria for antibiotic use suggests a deficiency in the facility's antibiotic stewardship efforts. A review of the facility's infection control log for December 2024 revealed 20 infections, including wound, skin, lung, fungal, and urinary infections. Notably, seven of these were urinary tract infections, but only one had a documented urine culture and sensitivity test. The remaining six urinary tract infections were treated with antibiotics without such testing. Additionally, the facility did not track organisms for residents who came from the hospital on antibiotics, citing difficulty in obtaining lab results. The facility's document on antibiotic stewardship, last revised in October 2022, outlines the need for infection validation using McGreer's Criteria and routine review of culture and sensitivity reports, which was not consistently followed, leading to the identified deficiency.
Failure to Document and Administer Pneumococcal Vaccines
Penalty
Summary
The facility failed to ensure proper screening and documentation for influenza, pneumonia, and COVID-19 immunizations for residents. Specifically, three residents were not screened for pneumococcal vaccines, and there was no documentation of either vaccine administration or signed declinations. One resident had not received an updated pneumococcal vaccine since 2000, while two others had no records of receiving or declining the vaccine. During an interview, a staff member admitted to being unaware of her responsibility for immunizations and only ordered the vaccines after the surveyor's request. The facility's policy on pneumococcal immunization, revised in November 2024, outlines the need for resident education and vaccine administration unless contraindicated or refused, but this was not adhered to in practice.
Failure to Respect Resident's Request for Hospital Transfer
Penalty
Summary
The facility staff failed to respect a resident's rights by not following up on a request to be sent to the emergency room when the resident was not feeling well. The incident involved a resident who expressed feeling unwell and requested to go to the hospital. Despite the resident's request and low oxygen levels, the facility staff did not arrange for the transfer. Instead, a non-facility caregiver visiting the resident called an ambulance without notifying the facility, leading to the resident's transport to the hospital. Interviews with staff members revealed that the nurse on duty was aware of the resident's condition, and another staff member was present when the ambulance arrived. The facility's document on Resident's Rights emphasizes the resident's right to a dignified existence, self-determination, and participation in their treatment. However, the facility's inaction in this situation resulted in a failure to uphold these rights, as the resident's request for medical attention was not addressed by the facility staff.
Delayed Reporting of Neglect Allegation
Penalty
Summary
The facility failed to report an allegation of neglect involving a resident to the State Survey Agency within the required 24-hour timeframe. The incident involved a resident who was not feeling well and requested to be sent to the hospital, claiming neglect by the facility staff for not sending her. The incident occurred on December 30, 2024, but was not reported to the state until January 1, 2025, after an anonymous complaint was submitted through the facility's website. This delay in reporting was acknowledged by staff members who were aware of the incident but did not act promptly. The facility's policy on abuse, revised in July 2019, mandates immediate reporting of allegations of neglect to the Executive Director and the state agency. Despite this policy, staff members failed to report the incident in a timely manner. Internal communication showed that staff were reminded to follow up within 24 hours, yet the report was delayed. The failure to adhere to the reporting policy resulted in a deficiency being cited during the survey.
Failure to Monitor Resident's Oxygen Needs and Hospital Transfer
Penalty
Summary
A deficiency was identified in the facility's care for a resident who required monitoring for oxygen needs and potential transition to an acute care facility. The resident expressed feeling unwell and requested to go to the hospital, but the facility staff did not take immediate action. The resident's vital signs showed an oxygen saturation of 71%, which is critically low, yet the staff did not document any follow-up assessments or vital signs after the initial evaluation. The resident's non-facility caregiver eventually called an ambulance, and the resident was transported to the hospital. The facility's documentation policy requires that the medical record accurately reflect the resident's health status, including changes in condition and actions taken. However, the facility failed to provide documentation of follow-up assessments or actions taken in response to the resident's condition. This lack of documentation and failure to act promptly on the resident's request and low oxygen levels contributed to the deficiency identified by the surveyors.
Deficiencies in Oxygen Therapy Management and Equipment Labeling
Penalty
Summary
The facility failed to ensure that physician orders for oxygen therapy were present in the electronic health records (EHR) for two residents. During observations and interviews, it was found that one resident was receiving oxygen therapy without a documented physician order, and another resident had an oxygen concentrator in their room without a corresponding order in their medical record. Staff members expressed uncertainty about the necessity of having a physician order for oxygen therapy, and the facility did not have standing orders for oxygen. Additionally, the facility did not consistently label oxygen supplies and equipment with the date they were cleaned or changed for five residents. Observations revealed that residents' oxygen tubing, humidifiers, nebulizers, and CPAP equipment were not labeled with dates, and residents reported not seeing staff clean or label their respiratory equipment. The facility's policy required verification of a physician order before initiating oxygen therapy, but this was not adhered to, leading to deficiencies in the management of respiratory care.
Failure to Implement Resident Dietary Preferences and Timely Address Diet Changes
Penalty
Summary
The facility failed to properly implement and encourage dietary preferences for a resident, leading to a deficiency in care. The resident expressed difficulty swallowing dry or tough meats and preferred them with sauce or gravy. Despite these preferences being communicated during a care conference, the resident's diet order was changed without a swallowing assessment, and the resident was served minced pancakes, which she found inappropriate. Additionally, the resident's food often lacked gravy due to concerns about weight gain, which was not aligned with her preferences. The facility also lacked a consistent process to address therapeutic diet changes over the weekend. A staff member noted that diet orders were printed on Fridays, and any changes made after that time could be missed until the following Monday. This inconsistency was evident when the resident's diet order was not followed, as observed during breakfast, where the resident received cubed ham instead of minced ham, and scrambled eggs without cheese, contrary to the diet order. The resident also received milk despite expressing a preference against it due to a potential allergy. The facility's policy required changes in diet orders to be communicated to the Culinary Services department within two hours, but this was not adhered to. The resident's electronic health record showed a diet order change without accompanying documentation of a swallowing evaluation or physician communication. The lack of timely communication and adherence to dietary preferences and orders contributed to the deficiency, as evidenced by the resident's dissatisfaction and the staff's acknowledgment of the discrepancies.
Inadequate Legionella Prevention and Control Measures
Penalty
Summary
The facility failed to maintain water temperatures within the CDC's recommended range to prevent the growth of Legionella bacteria. The facility's policy required weekly temperature checks, but records showed that checks were conducted bi-weekly, with temperatures recorded within the favorable range for Legionella growth. Residents reported never seeing staff check water temperatures in their rooms, and observations revealed dirty toilets and sinks with residue that could harbor bacteria. Staff interviews revealed a lack of specific education on Legionella prevention, with staff unaware of symptoms beyond cough and pneumonia. Staff were not informed about the importance of cleaning water-related areas, such as sinks and toilets, to prevent Legionella. Documentation of staff education on Legionella was requested but not provided, indicating a gap in training and awareness among staff members. The facility's infection preventionist did not provide oversight or intervention when a resident was diagnosed with Legionella. Staff interviews indicated confusion about responsibilities and a lack of increased preventative measures following the diagnosis. The facility's Legionnaire Disease Outbreak Protocol required staff education and documentation, but these were not adequately implemented, contributing to the deficiency.
Inadequate Assistance and Smoking Hazards in LTC Facility
Penalty
Summary
The facility failed to provide adequate assistance to prevent injury for a resident, resulting in a fractured hip. The resident, who has a self-care performance deficit related to multiple sclerosis and requires assistance from two staff members for toilet transfers, was only assisted by one CNA during a transfer. This lack of proper assistance led to the resident falling and injuring his hip, necessitating surgery. The investigation into the incident was incomplete, as the investigation file was missing, and the education related to the incident was unavailable for review. Additionally, the facility did not ensure a safe environment free from smoking hazards. A resident was found with a marijuana vape pen in his bed, which he used regularly despite the facility's prohibition of medical marijuana use. Staff were aware of the resident's vaping but did not take action due to concerns about residents' rights and management's instructions. The presence of the vape pen posed a potential fire hazard, especially in a facility with oxygen in use. Furthermore, two other residents were found to be smoking on the facility's premises, contrary to the facility's smoke-free campus policy. These residents smoked outside by the dumpsters and in the parking lot, with staff being aware of their activities. The facility's policy requires residents and staff to refrain from smoking on the premises, but this was not enforced, creating additional safety hazards.
Failure to Conduct and Document Care Conferences
Penalty
Summary
The facility failed to conduct quarterly and annual care conferences and include residents and their representatives in the development and implementation of person-centered care plans. This deficiency was identified for seven residents who were part of the sample investigated. Interviews with residents and their representatives revealed that they were not invited to attend care conferences, and some were unaware of the opportunity to participate in their care planning. For instance, one resident expressed willingness to attend if invited, while another representative reported not being able to provide input on care concerns due to lack of invitation. The review of electronic health records (EHR) for the sampled residents showed that care conferences were not documented for several required periods, including quarterly and annual Minimum Data Set (MDS) assessments. For example, one resident had not had a care conference since March of the previous year, missing several quarterly MDS assessments. Another resident's representative, who lived far away, had arranged for monthly care calls but had not been included in care conferences since the resident's admission. This lack of documentation and participation was consistent across all sampled residents. Interviews with staff members revealed awareness of the delays and lack of care conferences. One staff member mentioned plans to conduct five care conferences a week to catch up, while another staff member acknowledged the backlog and had created a list of residents who had not had recent care conferences. Despite recognizing the issue during a mock survey, the facility did not provide a policy and procedure for care conferences when requested, indicating a systemic issue in managing and documenting care conferences.
Failure to Inform and Document Grievance Process
Penalty
Summary
The facility failed to ensure that residents were informed about the grievance process and how to file grievances, as evidenced by interviews with multiple residents who were unaware of grievance forms or the process. Several residents expressed that they did not know how to file a grievance and had to rely on external parties like the ombudsman or the State Survey Agency to voice their concerns. Additionally, some residents requested immediate assistance from staff to complete grievance forms, indicating a lack of accessible information and support within the facility. Staff interviews revealed that there was a lack of proper handling and documentation of grievances. Staff member A admitted to not being diligent in filling out grievances and preferred to address issues directly, which could lead to underreporting. Other staff members reported being instructed by a previous administrator not to file grievances or provide residents with the ombudsman's contact information, further complicating the grievance process. This lack of formal grievance handling was reflected in the facility's grievance logs, which showed minimal entries over several months, despite numerous complaints raised during resident council meetings. The facility's grievance policy required that complaints be acknowledged, investigated, and documented, with evidence maintained for at least three years. However, the facility failed to maintain proper documentation of grievances and investigations, as evidenced by the inability of staff to locate grievance logs or supporting documentation for concerns raised in resident council meetings. This failure to document and address grievances could potentially result in unrecognized and unaddressed issues related to resident care and services.
Failure to Report Abuse Allegations and Investigation Results
Penalty
Summary
The facility failed to report allegations of abuse and the results of an investigation to the State Survey Agency and Adult Protective Services. In one instance, a resident reported that a CNA had verbally abused her and physically restrained her in the bathroom. Despite the resident expressing fear and requesting counseling, the staff dismissed her claims as deflection and did not conduct an investigation or report the incident to the appropriate authorities. The facility's reporting system showed no record of this alleged abuse being reported. In another case, a resident suffered rib fractures following a fall, and the incident was initially reported to the State Survey Agency. However, the final investigation results were not submitted within the required timeframe. The facility's policy mandates that allegations of abuse and serious injuries be reported immediately, with investigation results submitted within five working days. The failure to adhere to these reporting requirements constitutes a deficiency in the facility's handling of abuse allegations and incident investigations.
Failure to Investigate and Report Alleged Abuse
Penalty
Summary
The facility failed to thoroughly investigate and prevent further potential abuse during an ongoing investigation of alleged abuse by staff towards a resident. The resident reported that a CNA had verbally abused her by calling her 'white trash' and that another resident had threatened her over a soda. Despite these allegations, the facility did not offer the resident counseling, and staff dismissed the incident as 'old news' during a care conference. The staff member interviewed admitted to not conducting a proper investigation into the resident's claims. The facility's records showed no reports of the alleged abuse to the State Survey Agency, nor was there a final 5-day summary sent after the investigation. The facility's policy requires immediate reporting of such allegations to the CEO and the state agency, which was not followed. Additionally, the resident's electronic health records did not reflect any notes of accusations of abuse by staff, indicating a lack of documentation and follow-through on the part of the facility.
Failure in Pressure Ulcer Prevention and Management
Penalty
Summary
The facility failed to prevent the development and worsening of pressure ulcers for two residents, resulting in significant deficiencies in care. Resident #6 developed a sacral pressure ulcer that progressed from Stage III to Stage IV over a period of time. The staff did not identify, report, or assess the resident's skin condition in a timely manner, nor did they implement necessary interventions to reduce skin pressure. Additionally, there were multiple missed dressing changes, and the resident experienced pain from the wound. The resident's condition was further complicated by inadequate wound care management, including instances where the resident was sent to the wound clinic without a dressing. Resident #15 developed a Stage III pressure ulcer as a result of a skin tear caused during care provision. The skin tear was attributed to improper use of a Hoyer lift sling, which was pulled from under the resident instead of rolling her side to side. The facility failed to assess the proper sling size and did not implement a care plan to prevent pressure ulcers, despite the resident being at risk. The resident's condition was exacerbated by the lack of timely wound care and assessment, leading to the progression of the skin tear to a Stage III pressure ulcer. The report highlights significant lapses in the facility's wound care management and pressure ulcer prevention strategies. Both residents experienced avoidable deterioration in their skin conditions due to the facility's failure to adhere to physician orders for wound care and to implement effective preventive measures. The deficiencies in care resulted in unnecessary pain and suffering for the residents, as well as a failure to provide the standard of care required to prevent and manage pressure ulcers effectively.
Failure to Follow Wound Care Protocols Leads to Stage IV Pressure Ulcer
Penalty
Summary
Licensed nursing and certified staff at the facility failed to adhere to professional standards of practice for wound care, resulting in a resident developing a pressure ulcer that deteriorated to a Stage IV. The resident, who was at high risk for pressure ulcers with a Braden score of 12, initially had intact skin upon admission. However, over the course of several months, the resident's condition worsened due to the staff's failure to follow physician orders for wound care treatments. Interviews with staff members revealed that while they were aware of the necessary interventions, such as turning and repositioning residents every two hours and reporting changes in skin condition, these practices were not consistently implemented. The review of the resident's medical records indicated multiple missed dressing changes, with a total of 17 missed instances documented. Specific dates were noted where dressing changes were not performed as ordered, including daily changes, every other day, and three times weekly schedules. Additionally, the resident arrived at the wound clinic on two occasions without any dressings on the wound, further highlighting the lack of adherence to prescribed wound care protocols. This failure to follow established wound care standards contributed to the deterioration of the resident's pressure ulcer.
Deficiencies in Care Planning for Pressure Ulcer Prevention and Pain Management
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for two residents, leading to deficiencies in their care. Resident #15, who was at risk for developing pressure ulcers as indicated by the Braden Scale, developed a Stage III pressure ulcer on her back due to improper handling with a mechanical lift. Despite the known risk and the development of wounds, the care plan for Resident #15 did not include problems, goals, or interventions for the prevention of pressure ulcers or for the treatment of existing ones. This oversight occurred even though the resident had started attending a wound clinic and was no longer receiving wound care from the facility staff. Additionally, Resident #6 experienced pain during wound dressing changes, yet the care plan failed to include interventions for pain management related to wound care. Although pain medication was ordered to be administered every six hours as needed, there was no clear documentation indicating whether the medication was given prior to dressing changes when the resident complained of pain. This lack of a specific pain management plan in the care plan contributed to the resident's discomfort during necessary medical procedures.
Inadequate Pain Management During Dressing Changes
Penalty
Summary
The facility failed to provide appropriate pain management for a resident during pressure ulcer dressing changes. The resident, who was readmitted after surgical repair of a hip fracture, had a skin condition that progressed to a Stage IV ulcer. Despite orders for pain medication to be administered 30 minutes prior to wound clinic appointments, the resident's medical records did not clearly document whether pain medication was given before dressing changes. Interviews with staff indicated that pain complaints were to be reported to the nurse, and pain medication should be administered prior to dressing changes if the resident complained of pain. However, the resident's care plan lacked interventions for pain management related to the wound and wound care, leading to inadequate pain relief during dressing changes.
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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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