Park Place Transitional Care And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Great Falls, Montana.
- Location
- 1500 32nd St S, Great Falls, Montana 59405
- CMS Provider Number
- 275030
- Inspections on file
- 27
- Latest survey
- April 9, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Park Place Transitional Care And Rehabilitation during CMS and state inspections, most recent first.
Surveyors found that dietary staff preparing and serving food did not wear required beard restraints despite visible facial hair, contrary to facility policy on employee personal hygiene. In addition, review of refrigerator temperature logs showed that two kitchen refrigerators had no recorded twice-daily temperature checks for a two-week period, with notes indicating the logs were lost, in violation of the facility’s policy requiring documented cooler and freezer temperatures to be maintained at or below 41°F.
A resident admitted with intact sacral skin developed a Stage III pressure ulcer that progressed to Stage IV, with healing not achievable. Despite interventions like an air mattress, repositioning, and wound care, documentation showed inconsistent repositioning, missed dressing changes, and incomplete wound assessments. The care plan lacked specific details about the wound, and pain management was not consistently provided before treatments, contributing to the ulcer's deterioration.
Surveyors found that food items in the kitchen were not properly labeled, dated, or discarded by their use by dates, and some were left uncovered or unlabeled. Additionally, refrigerator and freezer temperatures were not being monitored as required by facility policy. These failures may affect any resident receiving food from these storage areas.
The facility did not maintain a homelike environment by failing to control strong, persistent urine odors in a hallway, as observed over several days. Two residents and their visitors were affected, with one resident's family expressing concern about the overwhelming smell and the negative effects of excessive odor-masking sprays. Residents and families attempted to address the odor themselves, but the malodor remained present.
Contracted staff drew blood from a resident in a dining area without following proper infection control protocols, and facility staff did not provide additional training or enforce guidelines. For residents on droplet and contact precautions, required signage and PPE placement were not maintained, and staff entered rooms without appropriate PPE. In the kitchen, staff failed to change gloves or wash hands between handling soiled items and food, violating facility hygiene policies.
A resident who valued choosing her own clothing was not assisted in obtaining enough properly fitting clothes, resulting in her repeatedly wearing the same ill-fitting shirt and becoming distressed. Staff did not retrieve her personal clothing from her previous residence, and the facility's spare clothing did not fit, contrary to policy requiring residents to be dressed according to their preferences.
A resident with ongoing vision difficulties was not provided timely access to an eye doctor, despite repeated requests and documented need. Staff were aware of the resident's complaints and the lack of effective glasses, but no appointment was scheduled and transportation was not arranged, contrary to facility policy.
A resident with a history of neurogenic bladder and paraplegia, who previously managed his condition with intermittent self-catheterization, was admitted with an indwelling catheter. Despite a physician order for cognitive and self-catheterization assessment, the facility did not complete the evaluation or provide necessary supplies, leaving the resident with the indwelling catheter and without the opportunity to regain independence.
A resident with a history of stroke and new dialysis needs exhibited moderate depression and expressed interest in mental health counseling, but was not provided with behavioral health services or referrals. Staff recognized the resident's depressive symptoms, yet there was no documentation of follow-up or specific interventions, despite facility policy requiring person-centered behavioral health care.
A facility failed to identify a resident's elopement risk and did not update the care plan with interventions to prevent elopement. The resident, with severe cognitive impairment, was found wandering outside the facility. Staff members did not recognize this as an elopement, and the care plan was not updated promptly to include necessary interventions.
The facility failed to prevent elopement for two residents, one of whom was found by police hours later, and another who wandered outside unsupervised. The facility did not follow its care plan for hourly monitoring and failed to notify the legal representative or physician as per policy.
The facility failed to identify a severe 16% weight loss in a dialysis resident over two weeks due to discrepancies in weight recordings. The resident's pre-dialysis weights consistently decreased, but the facility's recorded weights were significantly higher, leading to a failure in recognizing the weight loss. Staff interviews and observations revealed issues with the weight monitoring process and malfunctioning scales.
The facility failed to continuously assess and document a resident's worsening penile ulcer. Despite recommendations for wound care and the facility's policy on perineal care, there were no nursing evaluations of the ulcer outside of the initial admission assessment. Staff interviews revealed that the resident's actions compromised wound care, but the facility did not document ongoing assessments or interventions.
A resident missed 15 days of prescribed medications, Flomax and Finasteride, intended to improve urine flow and assist in catheter removal. The error occurred due to incorrect physician orders, causing the resident anxiety about the upcoming catheter removal.
The facility staff failed to use standard precautions while handling soiled laundry, lacking protective gowns and gloves, which could lead to cross-contamination. This practice violated the facility's policy and CDC guidelines, as confirmed by staff interviews and observations.
A resident arrived at a follow-up appointment soiled with urine and dried stool, leading to feelings of embarrassment and humiliation. The resident reported not being toileted or changed all day, and her medical records showed 37 instances of incontinence within a month. Despite this, facility staff denied the resident was soiled prior to the appointment, and a grievance filed by the family member was dismissed as an accident.
A resident with a history of left-sided weakness from a stroke experienced an unwitnessed fall resulting in a fractured hip. The facility failed to conduct a root cause analysis to determine the cause of the fall or implement preventive measures, despite their policy requiring such actions.
The facility failed to complete an accurate MDS assessment for a resident with bowel and bladder incontinence. Despite the resident and medical records indicating incontinence, the MDS assessment inaccurately reported continence, leading to a deficiency in providing appropriate care.
The facility failed to implement a baseline care plan within 48 hours for a new resident who required assistance with dressing, toileting, and bathing. The care plan was not completed until 14 days after admission and lacked essential information. Staff members provided inconsistent information about the resident's condition and care needs, and one staff member was unaware of how to access the care plan.
The facility failed to complete a comprehensive, person-centered care plan for a resident with a knee fracture, resulting in inconsistent care and unmet needs related to ADLs, bowel and bladder status, and physical therapy services.
Failure to Enforce Beard Restraints and Maintain Refrigerator Temperature Logs
Penalty
Summary
The deficiency involves failures in food service safety practices related to staff personal hygiene and monitoring of refrigeration temperatures. Surveyors observed one dietary staff member preparing sandwiches in the kitchen without a beard net despite having visible facial hair, and another dietary staff member serving food onto resident trays from a steam table without a beard net covering his facial hair. The facility’s own policy on Dietary Employee Personal Hygiene requires all dietary staff to wear hair restraints, including beard restraints, to prevent hair from contacting food. During an interview, a dietary staff member confirmed that kitchen staff with beards or mustaches were expected to wear facial coverings while working in the kitchen. The deficiency also includes incomplete monitoring and documentation of refrigerator temperatures. Review of the Daily Freezer/Refrigerator Temperature Logs for March 2026 showed that for refrigerators labeled R1 and R4, there were no recorded twice-daily temperature checks for days 1–15, and each log contained a note stating “Lost these ones” in the section for those days. The facility’s Monitoring of Cooler/Freezer Temperature policy requires that logs for each refrigerator or freezer be posted in a visible location and that temperatures be checked and logged at least twice per day, with refrigerated storage maintained at or below 41°F unless otherwise specified by law. During an interview, the dietary staff member responsible for the logs stated she did not know why the logs for those periods had no temperatures recorded and thought the logs had been misplaced.
Failure to Prevent and Manage Pressure Ulcer Progression
Penalty
Summary
A resident who was admitted with intact skin on the sacrum developed a Stage III pressure ulcer that progressed to a Stage IV, with healing ultimately not achievable. The resident was dependent on staff for all care needs and had a history of medical co-morbidities, increasing the risk for pressure ulcers. Although interventions such as an air mattress, repositioning, use of a wedge, and a cushion in the wheelchair were implemented, documentation showed that repositioning every two hours was not consistently performed or recorded. The care plan specified limited time in a wheelchair and frequent repositioning, but these interventions were not reliably documented or executed. Wound care documentation was inconsistent, with measurements and identification of undermining and tunneling not reliably recorded. Dressing changes ordered by the physician were missed on multiple occasions, as evidenced by gaps in the treatment administration records. The wound was identified as infected at one point, and the resident received several courses of antibiotics for wound infection and cellulitis. However, the care plan did not specify the location or severity of the wound, and interventions for pain management prior to wound treatments were not consistently documented, despite the resident refusing some treatments due to pain. Staff interviews indicated that the resident occasionally refused repositioning, but staff generally believed the resident did not frequently refuse care. There was a lack of consistent documentation regarding refusals and pain management interventions. The combination of missed repositioning, incomplete wound care documentation, missed dressing changes, and insufficient pain management contributed to the failure to prevent the development and worsening of the pressure ulcer.
Failure to Properly Store, Label, Date, and Monitor Food Items and Temperatures
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen regarding the storage, labeling, dating, and discarding of food items. Specifically, in the backroom cooler, several food items were found either past their use by date, not labeled, not dated, or not properly covered. Examples included tortillas with an expired use by date, a potato-like item wrapped in foil without a label or date, beef and mushrooms in pans or bags without labels or dates, uncovered and unlabeled hotdogs, ground beef, deli ham, sausages with only a date, and chicken with two different dates. Staff confirmed that the use by date should be seven days after opening, and facility policy requires proper labeling, dating, and timely use or disposal of refrigerated foods. Additionally, the refrigerator next to the juice dispenser lacked a temperature log, and there was no evidence of temperature monitoring for that unit. Staff confirmed that all refrigerator units should have their temperatures monitored. Facility policy also mandates daily and routine monitoring of food temperatures and refrigeration equipment to ensure safe storage. These failures may affect any resident consuming food from these storage areas.
Failure to Control Persistent Urine Odors in Resident Hallway
Penalty
Summary
The facility failed to maintain a homelike environment and adequately control persistent urine odors in the 400B hallway, affecting two of 39 sampled residents and their visitors. Multiple observations over several days documented a strong, unpleasant urine smell throughout the hallway. Interviews revealed that one resident, who previously maintained a clean home before a dementia diagnosis, would not have tolerated such conditions, and her family expressed concern about the overwhelming odor upon her relocation to the hallway. The family also noted that excessive use of odor-masking spray caused the resident to cough, and they attempted to mitigate the smell with personal air fresheners and a fan. Another resident also commented on the persistent malodor in the area.
Infection Control Failures in Blood Draws, Precautions, and Kitchen Hygiene
Penalty
Summary
Contracted staff failed to follow safe and effective blood-draw practices by attempting to draw a resident's blood in the main dining room while the resident was eating breakfast and another resident was present at the table. The contracted staff stated they had been told by a facility staff member that they could draw blood in the dining room if the resident consented, and they confirmed they had not received any additional training on the facility's infection control expectations. Facility staff interviews revealed that contracted staff were expected to follow the facility's guidelines and not perform blood draws in common areas, but no additional training or clear communication of these expectations had been provided to the contracted staff. The facility did not implement appropriate transmission-based precautions (TBP) for residents on droplet and contact precautions. For a resident on droplet precautions due to parainfluenza virus pneumonia, there was no signage on the outside of the door, and personal protective equipment (PPE) was stored inside the room rather than outside, contrary to facility policy. Staff interviews confirmed that signage and PPE placement did not meet policy requirements, and documentation showed the resident was on droplet precautions at the time of the observation. For another resident on contact precautions due to a methicillin-susceptible Staphylococcus aureus (MSSA) infection, PPE was inconsistently placed, and staff were observed entering the room without donning PPE, despite policy requiring PPE to be donned before room entry. In the kitchen, staff failed to follow proper hand hygiene and glove use protocols. One staff member was observed sweeping the floor with gloved hands and then handling food items without changing gloves. Another staff member handled both soiled items and ready-to-eat food with the same pair of gloves, without changing gloves or washing hands between tasks. Facility policy required gloves to be changed between tasks and for staff to adhere to hygienic practices to prevent food contamination, but these procedures were not followed during the observations.
Failure to Provide Resident with Properly Fitting and Sufficient Clothing
Penalty
Summary
A resident who was cognitively intact and valued choosing her own clothing was not provided with adequate or properly fitting clothes during her stay. Despite having personal clothing available at her previous assisted living facility, staff did not make efforts to retrieve these items or ensure she had enough suitable clothing. Observations over several days showed the resident repeatedly wearing the same ill-fitting shirt, and her closet was found to be empty except for a few items, none of which fit appropriately. The resident expressed distress about her lack of appropriate clothing, becoming tearful when discussing the issue. Interviews with staff revealed that while spare clothing was available in a linen closet, it was often used for residents admitted from hospitals, and there was an expectation that social services would contact families for additional clothing when needed. However, no staff had requested the resident's clothing from her previous residence, and the clothing provided by the facility did not fit. Facility policy required residents to be groomed and dressed according to their preferences, but this was not followed in the resident's case, impacting her dignity and emotional well-being.
Failure to Arrange Timely Vision Services for Resident
Penalty
Summary
A deficiency occurred when the facility failed to ensure a resident received proper treatment, services, and assistive devices to maintain optimal visual abilities. The resident repeatedly reported difficulty seeing, even with the glasses provided, and expressed frustration over not being able to see the eye doctor despite multiple requests. Observations confirmed the resident's ongoing struggle to watch television and read, and interviews with staff revealed that no eye appointment had been scheduled, even though the need was documented in progress notes and communicated among staff. The resident's only available glasses were simple readers brought in by a family member, and his magnifying glass was broken and awaiting replacement by his sister. Documentation showed that a referral for an eye exam was made by the provider, and staff were aware of the resident's visual difficulties, but there was no evidence that an appointment was scheduled or transportation arranged. The facility's policy required staff to refer identified needs for vision services to social services, who were then responsible for making appointments and arranging transportation. Despite these requirements and ongoing monitoring, the resident did not receive timely access to necessary vision services.
Failure to Assess and Support Self-Catheterization for Resident with Indwelling Catheter
Penalty
Summary
A deficiency occurred when the facility failed to address the discontinuation of an indwelling urinary catheter for a resident who was admitted with the device. The resident, who is paraplegic and has a history of neurogenic bladder, previously managed his condition through intermittent self-catheterization and expressed a desire to return to this method for greater independence. Upon admission, the resident communicated his preference and history to staff, and a physician order was placed to assess his cognitive and physical ability to resume self-catheterization. However, no such assessment was completed, and the resident continued to have an indwelling catheter in place. Multiple staff interviews revealed a lack of awareness regarding the referral and physician order for the necessary cognitive and self-catheterization assessment. Documentation confirmed that no therapy evaluation or cognitive assessment was performed, and the order was not present on the facility's communication board. Staff also indicated that there was confusion about how to order self-catheterization supplies, and no supplies were procured for the resident. The facility's own policies require timely assessment for catheter removal and appropriate services to restore continence or independence, but these were not followed in this case. The resident did not receive the ordered evaluation to determine his ability to self-catheterize, nor was he provided with the supplies or services needed to restore his previous level of independence. The failure to complete the assessment and provide appropriate care was confirmed through record review, staff interviews, and observation, demonstrating noncompliance with facility policy and professional standards of practice.
Failure to Provide Behavioral Health Services for Resident with Depression
Penalty
Summary
A deficiency was identified when the facility failed to provide necessary behavioral health services to a resident who exhibited signs of depression following a significant life-changing event. The resident, a former school teacher who suffered a stroke resulting in right-sided weakness and the need for dialysis, expressed feelings of sadness, loss of independence, and uncertainty about recovery. During interviews and observations, the resident was noted to be tearful, reported not being approached about mental health services, and expressed interest in counseling, stating that it could help him mentally. Staff interviews confirmed awareness of the resident's depressive symptoms, with one staff member acknowledging that the resident seemed depressed and would likely benefit from mental health counseling. Despite this, there was no documentation of any follow-up or referral for behavioral health services, and the resident's participation in activities was minimal. The staff member who completed the PHQ-9 assessment upon admission recalled discussing mental health therapy with the resident but admitted there was no documentation of this conversation. Review of the resident's records showed a PHQ-9 score indicating moderate depression at admission, with no subsequent assessments completed before the survey. The care plan identified mood problems and included general interventions such as encouraging meaningful activities and monitoring mood, but there were no specific interventions or referrals for behavioral health services documented. The facility's policy requires person-centered behavioral health care, but the lack of documented interventions or referrals for the resident's depressive symptoms constituted a failure to provide necessary behavioral health services.
Failure to Identify and Address Elopement Risk
Penalty
Summary
The facility failed to identify a resident's risk of elopement and did not update the care plan with necessary interventions to prevent such incidents. The resident, who had a severe cognitive impairment as indicated by a BIMs score of 3, was found wandering outside the facility. Despite this incident, staff members did not recognize it as an elopement. Staff member A observed the resident near the doors but did not consider the resident's actions as an elopement. Staff members B and D were unaware of the resident's tendency to sit near the doors or go outside alone, while staff member C, who was familiar with the resident's habits, was informed of the wandering incident after it occurred. The care plan for the resident was not updated in a timely manner following the elopement incident. It was only on a later date that interventions were added to the care plan to prevent further elopements. This delay in updating the care plan highlights a lapse in the facility's response to the resident's elopement risk, as the necessary interventions were not promptly implemented to ensure the resident's safety.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to identify and manage the elopement risk for two residents, leading to incidents where both residents left the facility unsupervised. One resident, identified as having a high elopement risk, was able to leave the facility and was found by the police several hours later, a significant distance away. The facility did not adhere to its care plan, which required hourly monitoring and checking the functionality of the resident's wander guard bracelet. The incident report indicated a lapse in monitoring, as the resident was last seen at 3:00 a.m. and was not found in their room at 4:15 a.m., with the elopement being reported to authorities at 5:00 a.m. Another resident, who had severe cognitive impairment, was found wandering outside the facility. The nursing notes did not document the notification of the resident's legal representative or attending physician, nor was the resident reassessed upon return, as required by the facility's elopement policy. Staff interviews revealed inconsistencies in awareness and monitoring of the resident's behavior, with some staff unaware of the resident's tendency to sit near exit doors. The resident's care plan was not updated with interventions to prevent further elopement until after the incident.
Failure to Identify Severe Weight Loss in Dialysis Resident
Penalty
Summary
The facility failed to identify a significant discrepancy in weight recordings for a dialysis resident, leading to a severe 16% weight loss over two weeks. The resident's Dialysis Communication Records showed a consistent downward trend in weight, with no body or fluid weight gain between treatments. Despite this, the facility's weekly weight summary showed conflicting weights, which were used in the IDT weight meeting and failed to identify the resident's weight loss. The resident's pre-dialysis weights consistently decreased, but the facility's recorded weights were significantly higher than those recorded at dialysis, leading to a failure in recognizing the severe weight loss. Interviews with staff revealed that the weight monitoring process relied on the electronic health record dashboard and nursing concerns. Staff member M noticed the weight loss only after observing muscle and fat loss in the resident. Additionally, an observation of the weighing process showed that the mechanical lift scale was not functioning correctly, as it displayed an incorrect weight. Staff member A mentioned that maintenance had a schedule for calibrating the scales, but this did not prevent the discrepancy in the resident's weight recordings.
Failure to Continuously Assess and Document Worsening Penile Ulcer
Penalty
Summary
The facility failed to continuously assess and document the condition of a resident's penile ulcer, which was progressively worsening. The resident was admitted with skin concerns to the groin, including moisture and excoriation to the head of the penis. Despite the hospital discharge summary recommending wound care and noting the progression to a penile ulcer, the facility's records showed no nursing evaluations of the ulcer outside of the initial admission assessment. The facility's policy on perineal care required noting and reporting any skin changes, but this was not followed, as there was no documentation on the resident's penile ulcer or its worsening status in the nursing progress notes from the time of admission to the date of the surveyor's request for records. The care plan initiated later also failed to address the worsening condition adequately. Interviews with staff revealed that the resident's wound care was being compromised by the resident's actions, such as wiping off the applied wound care and touching himself, which made the wound care difficult. Despite these challenges, the facility did not document ongoing assessments or interventions to address the worsening ulcer, leading to a deficiency in providing appropriate treatment and care according to orders, resident’s preferences, and goals.
Medication Error Omission for Resident
Penalty
Summary
The facility failed to ensure a resident was free from a medication error omission, resulting in the resident missing 15 days of two prescribed medications, Flomax and Finasteride. These medications were intended to improve urine flow and assist in the resident's catheter removal. The resident had a urinary catheter placed due to urinary retention while in the hospital, and the plan was to continue these medications before a follow-up with urology. However, the resident's Medication Administration Record (MAR) showed that Finasteride was not administered, and Flomax was discontinued. The resident expressed anxiety about the upcoming catheter removal, and a staff member confirmed that the physician orders were not correctly followed, leading to the medication error.
Failure to Use Standard Precautions in Laundry Handling
Penalty
Summary
The facility staff failed to use standard precautions while handling soiled laundry, which could lead to cross-contamination. During an observation, it was noted that there were no protective gowns or gloves available for staff in the dirty linen area of the laundry room. A staff member confirmed that they did not use any personal protective equipment (PPE) while handling soiled laundry, simply throwing it into the washing machine without any covers or gloves. This practice was in direct violation of the facility's policy on handling soiled linen, which mandates the use of gloves and other protective equipment as necessary. Additionally, the facility's policy explicitly states that all used linen should be treated as potentially contaminated and should not come into contact with uniforms or the floor. The lack of adherence to these guidelines was further highlighted when another staff member inquired about the need to educate laundry staff on the proper use of PPE. The facility's failure to provide and enforce the use of appropriate PPE for laundry staff was also inconsistent with best practices outlined by the Centers for Disease Control and Prevention (CDC), which recommend the use of tear-resistant gloves, gowns, aprons, and face protection when handling soiled linens.
Failure to Provide Dignity and Respect to Resident
Penalty
Summary
The facility failed to provide dignity and respect to a resident, leading to feelings of embarrassment and humiliation. During a follow-up appointment at a local physician's office, the resident arrived soiled with urine and dried stool. The resident's incontinent brief was saturated and had leaked onto her clothing and wheelchair. The resident reported not being toileted or changed all day, which was corroborated by the nurse who assisted her at the appointment. The resident and her family member both expressed feelings of embarrassment and humiliation due to the incident. Upon returning to the facility, the resident's room had a strong urine smell, and she confirmed occasional bowel and bladder incontinence, requiring assistance with toileting. The resident had been living independently before her admission and had recently started to regain some independence. Despite this, the facility staff denied that the resident was soiled prior to her appointment. A grievance was filed by the family member, but the facility's investigation concluded that the resident was continent and the incident was an accident. However, the resident's medical records showed 37 instances of incontinence within a month, contradicting the staff's claims.
Failure to Conduct Root Cause Analysis for Resident Fall
Penalty
Summary
The facility failed to complete a thorough investigation, including a root cause analysis, for a fall with injury involving a resident. The resident, who had a history of left-sided weakness from a stroke, experienced an unwitnessed fall in his room, resulting in a fractured hip. Despite the resident being sent to the emergency room and undergoing surgery, staff members were unable to determine the cause of the fall or articulate any root cause analysis during interviews. The facility's policy mandates conducting root cause analysis to prevent recurrences and improve resident care, but this was not followed in this case. The incident report submitted to the State Survey Agency indicated that an investigation was started, but the findings did not include a root cause analysis. Staff interviews revealed that the resident might have fallen while attempting to walk to the bathroom, but no formal analysis was conducted to confirm this or to implement preventive measures. The facility's failure to conduct a root cause analysis and implement corrective actions as per their policy represents a significant deficiency in their management of resident care and safety.
Inaccurate MDS Assessment for Bowel and Bladder Incontinence
Penalty
Summary
The facility failed to complete an accurate MDS assessment for a resident in the area of bowel and bladder incontinence. During an observation and interview, the resident reported issues with bowel and bladder incontinence, which had worsened after knee surgery. Despite this, the resident's MDS assessment indicated that the resident was always continent of bowel and bladder. Interviews with staff members revealed inconsistencies in their knowledge of the resident's continence status, with some staff members stating the resident was continent and others being unfamiliar with the resident's condition. A review of the resident's electronic medical record showed 37 instances of incontinence over a one-month period, contradicting the MDS assessment. The case manager responsible for MDS assessments stated that the facility did not have a specific MDS policy and relied on the guidelines set forth in the RAI manual. The case manager also mentioned that another MDS nurse had completed the resident's MDS assessment while she was out of town. The facility's policy on incontinence indicated that residents who are incontinent should receive appropriate treatment and services to prevent infections and restore continence. However, the inaccurate MDS assessment failed to reflect the resident's actual condition, leading to a deficiency in providing appropriate care and services.
Failure to Implement Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to implement a baseline care plan within 48 hours of admission for a new resident, which is a requirement according to their policy. The resident, who had a knee brace and was non-weight bearing on her left leg upon admission, required assistance with dressing, toileting, and bathing. However, the baseline care plan was not completed and locked until 14 days after admission, and it did not address the resident's transfer status, weight-bearing status, or activities of daily living. During interviews, staff members provided inconsistent information about the resident's condition and care needs. One staff member stated the resident was continent of bowel and bladder, while another mentioned the resident had problems with incontinence. Additionally, a staff member who did not usually work on the unit was unaware of how to access the resident's care plan and relied on verbal reports for information. This lack of a timely and comprehensive care plan had the potential to affect the quality of care for all new admissions in the facility.
Incomplete Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to complete a comprehensive, person-centered care plan for a resident who had a knee fracture and was admitted to the facility non-weight bearing. The resident required assistance with activities of daily living (ADLs) such as dressing, toileting, and bathing. Despite the resident's progress in becoming more independent and being able to bear weight with a knee brace, the care plan did not include focus, goals, or interventions related to ADLs, bowel and bladder status, transfer status, weight-bearing status, or physical therapy services. This omission was observed during interviews and record reviews, where staff members provided inconsistent information about the resident's needs and care plan details. During observations and interviews, it was noted that the resident's room had a strong urine smell, and the resident reported occasional bowel and bladder incontinence. Staff members had varying levels of knowledge about the resident's condition and care needs, with some unable to access or verbalize the care plan. The facility's document on comprehensive care plans indicated that care plans should include measurable objectives and timeframes to meet the resident's needs, but this was not reflected in the resident's electronic care plan dated February 2024.
Latest citations in Montana
A dependent resident admitted post-surgery with intact but vulnerable skin and MASD risk developed significant bilateral buttock MASD and a sacral pressure injury that progressed from deep tissue injury to Stage III and then to a large unstageable ulcer with odor and purulent drainage. Facility records showed incomplete and missing weekly skin/wound assessments during the period when the wound worsened, despite a care plan calling for skin evaluations, turning/repositioning, CNA skin inspections, and monitoring of nutrition. Staff interviews revealed they were frustrated by the resident’s anxiety and behaviors, reported the sacral wound as facility-acquired, acknowledged the resident became obtunded on an intense opioid regimen, and stated they were unaware of excessive fluid intake and could not explain why the worsening wound and infection were not recognized or reported before the resident required hospital transfer for a severe sacral decubitus ulcer with associated infection.
Surveyors found that kitchen staff failed to properly label and date multiple food items stored in the walk-in cooler, including slimy sliced tomatoes, ground meat, sliced ham, roast beef, cheese, and strawberries. Staff reported that they sometimes picked moldy strawberries out of shipments and that moldy dinner rolls had been served and then collected from residents. These practices did not follow the facility’s written policy requiring labeling, dating, and monitoring of refrigerated foods so they are used by their use-by date or discarded, placing all residents at risk for foodborne illness.
The facility failed to submit required investigation findings to the State Survey Agency (SSA) within 5 working days for multiple abuse and elopement incidents. In one case, a resident kicked another resident’s feet, and in another, one resident kicked another in the legs while both were in wheelchairs; in both situations, the facility did not provide timely or, in one case, any investigative findings to the SSA. The facility also reported two separate elopement events for a resident but did not submit final investigation reports for either incident. A staff member reported that another staff member, who was absent during the survey, was responsible for SSA reporting, and confirmed the expectation to report all investigation results within 5 working days per facility policy.
Two residents were involved in a resident-to-resident abuse incident in which one resident kicked another multiple times while both were in wheelchairs, and although staff separated them and documented the event, the facility did not complete or document a formal abuse investigation, did not ensure ongoing protection from further confrontations, and did not report investigative findings to the SSA. In addition, several residents experienced multiple elopements, with documentation that one resident followed others out back doors and another exited through doors into a hospital area, yet the facility’s investigation files lacked clear timelines, comprehensive staff interviews, identification of information sources, and root-cause analyses of exit-seeking behavior. Staff interviews confirmed that while nurses submitted occurrence reports and SSA notifications and discussed root causes informally, management did not consistently document thorough investigations or root-cause findings as required by facility policy.
The facility failed to provide adequate supervision and effective elopement-prevention interventions for several cognitively impaired, exit-seeking residents who were known elopement risks. Despite assessments, care plans, anti-wandering devices, and door alarms, residents repeatedly exited through front and back doors without timely staff redirection or alarm response, and some elopements were not properly documented in the EHR. One resident with dementia and short-term memory loss was not care planned for elopement until after multiple attempts, and another resident with severe cognitive impairment left through sliding doors unnoticed. A resident with an anti-elopement alarm on her wheelchair repeatedly triggered the door alarm throughout the day, yet staff did not effectively respond, allowing her to exit unsupervised and fall on stairs, sustaining minor injuries.
The facility failed to provide meaningful, resident-centered activities for multiple dementia residents in the memory care unit, resulting in individuals sitting idle in dining and common areas, staring at blank or inappropriate televisions, sleeping in chairs, or wandering hallways without engagement. Activity sessions were canceled or not implemented as scheduled, and when paper activities like word searches were offered, only a few residents participated while others received no assistance, including a resident who repeatedly requested glasses and another who did not speak English. Sitters did not help residents with activities, and an activity staff member spent time on a computer and left the unit for other duties. Staff interviews revealed that management directed the limitation of music and physical activities, that residents were often left in bed because it was easier for staff, that floor staff did not conduct activities in the absence of the activity staff, and that the posted activity calendar, which included exercise, trivia, book club, and weekend "Resident Choice Day," was frequently not followed despite a policy requiring meaningful activities tailored to dementia residents.
A hospice resident with metastatic cancer and behavioral symptoms received multiple sedating medications, including quetiapine, hydrocodone, morphine, lorazepam, olanzapine, and prednisone, without thorough assessment for unnecessary drugs, duplicate therapy, or adverse consequences. Despite documented behavioral issues, falls, cognitive decline, and moderate to severe pain scores, staff reported no concerns with the medication regimen. The resident became increasingly sedated, was found unconscious with minimal response to painful stimuli, and was sent to the hospital, where documentation linked the clinical picture to disease progression and medication effects, including opioid use and possible steroid-induced psychosis.
A resident with a documented history of opioid-induced constipation and prior fecal impaction was admitted from the hospital, where providers had noted difficulty balancing opioid use and constipation medications. On admission, facility documentation characterized the resident as having normal stool and rarely needing laxatives. Over the following weeks, bowel records showed multiple days without a bowel movement, yet the MAR reflected no scheduled or PRN constipation medications given. Nursing notes documented no constipation despite absent bowel sounds, while subsequent hospital imaging revealed an extensive rectal stool burden concerning for stercoral colitis. Staff interviews confirmed that the prolonged absence of bowel movements was not reported, the resident received no PRN bowel medications, and there was no specific bowel and bladder management policy.
Staff failed to follow hand hygiene practices while caring for a resident with weeping, hot lower legs who had been started on antibiotics for cellulitis. One staff member removed TED hose from the resident’s weeping left leg and then immediately assessed the right leg without changing gloves or performing hand hygiene. Another staff member, after applying TED hose to the weeping leg while gloved, continued to handle the resident’s food, pillow, and personal items and answered a cell phone by placing her gloved hand into her pocket, all without changing gloves or performing hand hygiene, contrary to the facility’s hand hygiene policy.
The facility failed to protect residents from abuse when one resident without capacity to consent was found in a common area with another resident’s hand inside her brief, and the subsequent investigation did not include interviewing or assessing other residents who might have been affected. In a separate event, a resident shook his spouse’s head and later sprayed water in her face with a spray bottle when she was tired at dinner, causing her agitation, while both continued to share a room and she spent most of her time and slept in common areas due to ongoing behaviors between them, as reflected in her care plan.
Failure to Prevent and Manage Pressure Ulcer Leading to Severe Sacral Wound
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate prevention and treatment of pressure ulcers and to complete and document required skin and wound assessments for a dependent resident. The resident was admitted from a hospital with red skin on the right elbow, a left neck surgical laminectomy site, and a left shin abrasion, and was totally dependent on staff for bed mobility, transfers, dressing, toileting, personal hygiene, and bathing, and had a Foley catheter. Within six days of admission, weekly wound documentation showed the resident had developed bilateral buttock moisture-associated skin damage (MASD) of significant size. The resident was then hospitalized for confusion and hyponatremia, and hospital wound care documented a deep tissue pressure injury to the sacrum that evolved into a Stage III pressure injury with yeast. When the resident returned to the facility, the facility’s readmit screener documented MASD to the buttocks and a yeast rash to the buttocks and groin, but no sacral pressure injury. Subsequent facility wound documentation showed that a few days after readmission, the resident had scattered ulcerations with MASD to the buttocks and a Stage III pressure ulcer to the right medial lower buttock, and that orders for treatment were requested from the physician. By the following week, the weekly wound observation tool documented that the Stage III bilateral buttock wounds had merged into one large unstageable pressure ulcer with odor and moderate purulent drainage, indicating potential infection. During this same period, there were no documented skin/wound assessments for the week leading up to the resident’s transfer back to the hospital, and a staff member later stated she did not know where the assessments were or why they were not done, and could not explain why no one reported that the wound was worsening. The care plan listed multiple skin integrity problems and interventions, including skin evaluations, routine turning and repositioning, CNA skin inspections with routine care, monitoring nutrition, and weekly nurse skin evaluations, but did not specify task frequency for some interventions. Interviews further described staff awareness and handling of the resident’s condition and behaviors. A family member reported that staff were frequently frustrated by the resident’s constant need for attention and anxiety, and that he repeatedly educated management about the resident’s high anxiety and hyperfocus, and did not understand how staff could report spending so much time with the resident yet not recognize how sick he was with infection. A staff member stated the sacral wound was facility-acquired, that the resident became obtunded related to opioids, and that she was unaware of the resident’s excessive water intake until after a hospital stay. Another staff member who completed a readmission history and physical found the resident febrile, with therapy unable to mobilize him due to pain, and described the resident as heavily sedated on an intense pain regimen that predated his stay. This staff member stated there were many opportunities for improvement in nursing assessments and that the facility could not handle the resident’s complex psychiatric and pain needs. Ultimately, the resident was transferred to the hospital with a large sacral decubitus wound with purulent tissue, surrounding cellulitis, and radiologic evidence of a severe sacral ulcer with erosion nearly to the coccyx and associated abscess and necrotizing soft tissue infection.
Improper Labeling, Dating, and Handling of Refrigerated Food Items
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage practices when, during an observation of the walk-in cooler, multiple food items were found undated or unlabeled, contrary to the facility’s Food Safety Requirements policy. Specifically, two zip-lock bags of slimy, sliced tomatoes were not dated; a gallon zip-lock bag of ground meat was not labeled with the food type or date; and separate gallon zip-lock bags of sliced ham, sliced roast beef, and sliced cheese were all undated. In addition, a cup of sliced strawberries had no date. Staff interviews revealed that kitchen staff had observed mold on strawberries upon delivery and would usually attempt to pick out the molded strawberries, and another staff member acknowledged awareness of ongoing dating issues with refrigerated foods. A further interview indicated that moldy dinner rolls had been served on one occasion, prompting staff to retrieve the rolls from residents after service. The facility’s written policy required labeling, dating, and monitoring refrigerated food, including leftovers, so it would be used by its use-by date or frozen/discarded, but these requirements were not followed, placing all residents at risk for foodborne illnesses. No specific residents or their medical histories were identified in the report; the deficiency was described as affecting all residents through improper food labeling, dating, and handling practices in the kitchen and walk-in cooler.
Failure to Submit Abuse and Elopement Investigation Findings Within Required Timeframe
Penalty
Summary
The facility failed to submit investigation findings related to alleged abuse and elopement incidents to the State Survey Agency (SSA) within the required 5 working days for multiple residents. For one incident dated 1/24/26, a resident left her room and kicked another resident’s feet; the facility’s investigative findings for this event were not submitted to the SSA until 2/4/26, which was 11 days after the incident was reported. For another incident dated 3/20/26, one resident kicked another resident in the legs while both were in wheelchairs, with no injuries reported and immediate separation of the residents; review of records showed no evidence that the facility ever submitted investigative findings for this incident to the SSA. Additionally, review of the SSA reporting site showed that the facility made initial reports of elopement for a resident on 7/18/25 and 2/1/26 but did not submit final investigation reports within the required 5 working days. There were no final reports for either elopement incident. During an interview, a staff member stated that another staff member, who was out of the facility during the survey week, was responsible for reporting and submitting investigative findings to the SSA for abuse allegations. The same staff member confirmed the expectation that findings of any abuse allegation be reported to the SSA within 5 working days and acknowledged they could not provide investigative findings for the 3/20/26 incident. The facility’s written policy, reviewed and dated 7/15/25, required that results of all investigations of alleged violations be reported within 5 working days of the incident.
Failure to Investigate Resident Abuse and Elopements or Identify Root Causes
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and manage an allegation of resident-to-resident abuse and multiple resident elopements. In one incident, a resident in a wheelchair kicked another resident multiple times in the lower legs while both were at the nurses’ station. Nursing documentation noted the kicking and that there were no injuries, and the immediate response was to separate the residents. However, review of the facility’s abuse investigations for the relevant period showed no completed investigation related to this reported allegation of resident-to-resident abuse, and there was no documentation of investigative findings or that these findings were reported to the State Survey Agency. The facility also failed to protect the involved residents from further potential abuse. Nursing notes for both residents documented that, two days after the kicking incident, one resident was observed continually attempting to follow, communicate with, agitate, and argue with the other resident, and staff had to separate them twice. Staff communicated to others to monitor their interactions, but the notes showed that the residents continued to have problematic contact, indicating that the facility did not prevent further potential abuse between them. During interview, a staff member stated that another staff person was responsible for investigating and reporting abuse allegations, but that person was unavailable and no documentation could be produced to verify that an investigation had been completed or that results were reported to the state agency, despite facility policy requiring thorough investigation, protection of residents during the investigation, and reporting of results. The deficiency also includes failures related to multiple elopements by several residents. For one resident, an elopement investigation documented that the resident exited the facility, but the investigation lacked signatures, identification of information sources, and clear involvement of the email sender included in the file. A state abuse reporting entry indicated that this resident left through back doors, possibly following a volunteer or staff taking other residents to Mass, and was brought back by a Med-Surg nurse, but there was no documented root-cause analysis or explanation of why the elopement occurred or what interventions were implemented to prevent recurrence. Another resident eloped through doors leading into the hospital; the reportable incident was submitted to the SSA, but there were no nurses’ notes on the date of the elopement describing the event, and a note the following day only stated that the resident attempted to elope twice, reflecting incomplete contemporaneous documentation. For this same resident, the facility’s investigation of the elopement included only limited staff interviews and did not include interviews with CNAs or activity staff to establish a full timeline of the resident’s movements or to identify the root cause. A subsequent elopement by this resident into the hospital was documented in a nursing note, and the investigation consisted of an undated handwritten note stating that people came into the unit looking for someone in the hospital, left to go to Med-Surg, and the resident followed them out the door, with the door alarm functioning and the resident returning to the unit. There was no documented timeline, no detailed interviews, and no analysis of the effectiveness of elopement-prevention interventions. A third resident had multiple documented elopements over several months, with investigation files that often contained only brief summaries, incomplete checklists, or limited supporting documents such as bounds reports or invoices for a wander guard system. Across these events, the facility did not consistently document root-cause analyses or assessments of the resident’s exit-seeking behavior, and the record notes that this failure to identify and document root causes led to a fall with injury for this resident. Interviews with staff confirmed that the facility’s practice did not align with its stated expectations. One staff member reported that a former staff person had previously conducted incident investigations but had left months earlier, and that the expectation for investigations was to determine the root cause of incidents and monitor residents to ensure interventions were implemented. Another staff member stated that after each elopement, the nurse would file a report to the SSA and update the care plan, after which management was supposed to conduct a full investigation. A further interview indicated that nurses entered occurrence reports and submitted SSA reports to track elopements and that staff discussed root causes but did not maintain documentation of those analyses. These statements, combined with the incomplete and inconsistent investigation records, demonstrate that the facility did not carry out or document thorough investigations, root-cause analyses, or protective measures as required by its own abuse investigation and reporting policy.
Failure to Prevent Elopements and Respond to Anti-Wandering Alarms
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and effective interventions to prevent elopements for multiple residents identified as at risk for wandering, despite existing assessments and care plans. Staff reported that residents at risk for elopement were identified by the MDS nurse on admission and quarterly, and that anti-wandering devices and door alarms were in place, particularly at the front door. However, staff also indicated that wander guard bracelets could be applied without formal assessment, and that information about elopement risk was communicated via paper “brain” sheets. The facility had a written SBAR and procedure for anti-wandering door alarms, including immediate resident location checks and following an elopement procedure, but the report shows these processes were not effectively implemented. One resident with a documented elopement risk and dementia was care planned to have an anti-wander device on her wheelchair and to be involved in activities and redirected when she attempted to exit. She eloped on at least two occasions: once when she went through the first set of doors and was found in a corridor by another resident, and another time when she exited through back doors, apparently following others going to Mass, with no alarms triggered. Her care plan documentation was inaccurate regarding the presence of a wander guard door in 2024, and there was no nursing documentation of the February elopement in her electronic health record. Another resident with severe cognitive impairment (BIMS score of 3) and an elopement risk care plan that included redirection, diversional activities, and ensuring door alarms were activated, was able to get out between the sliding front doors when someone was entering or exiting, and no one saw her leave, contrary to the care plan interventions. A further resident with dementia and short-term memory problems was identified as at risk for elopement, yet his elopement care plan and interventions were not initiated until after he had already eloped twice in one afternoon through different doors. He later eloped again, but the corresponding nursing note was not provided. Another resident, described as exit seeking and very independent with behavioral issues toward staff, had an anti-elopement alarm device on her wheelchair that sounded as she approached the door and had been near the door setting off the alarm throughout the day. Despite this, she was able to push open the main entrance sliding doors, exit, and then fall while attempting to walk down stairs, sustaining an abrasion and bruising and requiring hospital evaluation. Staff interviews indicated that interventions such as 1:1 monitoring, taking her outside, and diversional tasks were used, and that elopements were tracked via occurrence reports and state submissions, but the facility failed to identify the need for continuous one-on-one monitoring for this resident, failed to respond appropriately to the anti-elopement door alarm, and failed to prevent her unsupervised exit and subsequent fall. Activity staff also reported that, after a staffing reduction, there were no organized activities after 5 p.m., despite prior recognition that increased monitoring and activities during late afternoon hours were needed for an elopement-risk resident.
Failure to Provide Meaningful Activities for Dementia Residents in Memory Care Unit
Penalty
Summary
The deficiency involves the facility’s failure to provide meaningful, resident-centered activities to meet the needs of multiple residents with dementia in the memory care unit. Surveyors observed residents sitting in dining and common areas without any activities, including a resident with a BIMS score of 0 repeatedly scratching her arms while staring at a turned-off television, and another resident wandering the unit and running into walls. On another observation, the scheduled activities were canceled due to weather, and the activity staff member present was working on care plans on a computer while residents sat with newsletters in front of them, many staring at the floor or sleeping. Only some residents participated in the offered activities, while others, including residents with severely and moderately impaired memory, did not participate and were not engaged. During the same observation period, residents were given a word search activity, but only a few actively worked on it. Sitters, who were present to watch and redirect residents, sat at the tables and did not attempt to assist residents with the activity. One resident repeatedly stated she needed her glasses to see the paper, but no staff obtained her glasses. A resident who did not speak English sat staring down the hall without engagement, and another resident with severe cognitive impairment wandered the hall. The activity staff member stated she had other duties in another unit and left, and later that evening, surveyors observed one resident sleeping in a recliner and another staring at a wall while cartoons played on the television. Interviews with staff revealed that activities in the memory care unit were limited and often not implemented as scheduled. The activity staff member reported she was instructed by management to avoid music and physical activities because staff believed these would cause residents to become agitated, and that she was told to limit activities to calming options only. She also stated that residents were often left in bed and not taken to activities because it was easier for staff, and that floor staff did not provide activities when she was not present, preferring residents to sit quietly. Other staff confirmed that activities usually did not occur in the memory care unit, that activities observed during the survey were a show for surveyors, and that the activity calendar was not followed. The memory care activity calendar showed “Resident Choice Day” on all weekends and listed trivia, exercise/stretching, and book club on weekdays, while the facility’s activities policy required activities to enhance well-being, physical activity, cognition, and to provide meaningful activities for residents with dementia.
Failure to Assess Hospice Resident’s Polypharmacy and Sedation Risk
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s drug regimen was free from unnecessary medications and thoroughly assessed for sedation, duplicate therapy, and adverse consequences. A hospice resident with metastatic cancer, delirium, psychosis, and impulsive, intermittently aggressive behavior was receiving multiple medications including antipsychotics, opioids, benzodiazepines, and a steroid. Hospice staff discontinued some medications and added morphine and lorazepam, while the resident also continued on quetiapine, hydrocodone, prednisone, and later received a one-time dose of olanzapine. Facility staff A and B reported that they had no concerns with the resident’s medications despite the combination of psychotropic and sedating drugs. The resident had been ambulatory on arrival to the facility but became weaker with multiple falls, nonsensical and incoherent speech, and combative and unsafe behavior. One-to-one supervision was initiated due to impulsivity and aggression, and staff questioned whether pain contributed to the aggressive behavior. The resident’s pain scores documented on the Medication Administration Record over three days showed moderate to severe pain levels (5/10, 3/10, and 7/10), while the resident continued to receive multiple sedating medications, including quetiapine every eight hours, hydrocodone three times daily, lorazepam as needed every four hours, morphine as needed every four hours, and prednisone daily. On the day before transfer to the hospital, the resident received olanzapine, prednisone, hydrocodone, two doses of lorazepam, and morphine; on the day of transfer, the resident received lorazepam, morphine, and prednisone. When a family member arrived at the facility, they found the resident unconscious with minimal response to painful stimuli and appearing sedated, and they requested transfer to the hospital. The family reported the resident had been more sedated at the facility lately, and the emergency room provider reportedly told the family the resident had an overdose of medications. Hospital documentation noted altered mental status, hypoxia, and that the resident’s dementia and chronic encephalopathy may have been exacerbated by disease progression and opioid use, possible steroid-induced psychosis, and electrolyte imbalance. The facility did not identify or address the resident’s medication regimen as a contributing factor to sedation or assess for duplicate therapy and adverse consequences prior to the resident’s transfer.
Failure to Monitor and Treat Constipation in Resident With Opioid-Induced Constipation History
Penalty
Summary
The facility failed to monitor and manage constipation for a resident with a known history of opioid-induced constipation and prior use of constipation medications. Hospital records showed the resident had been admitted with a 9.6 cm fecal impaction and that the hospital physician documented the resident could go up to five days without a bowel movement, likely due to opioid use, and was working on balancing opioid-induced constipation with constipation medications. Upon admission to the facility, the Admit/Readmit Screener documented that the resident had normal formed stool and rarely or never depended on laxatives, despite this history. Facility bowel documentation later showed gaps in bowel movements, including no bowel movement for several days. Review of the Medication Administration Record for March and April showed the resident did not receive any scheduled or PRN constipation medications during the stay. Bowel documentation indicated no bowel movement from 3/29 to 4/3, followed by diarrhea on 4/4 and a putty-like stool on 4/5. A nursing progress note on 4/6 documented a flat, non-tender abdomen with no bowel sounds and no constipation, while hospital records from the same date, after readmission, showed an extensive stool burden distending the rectum to 8.8 cm with findings concerning for stercoral colitis. Staff interviews revealed that no one reported the resident had gone six days without a bowel movement, the resident had gone without any PRN bowel medications, and the facility did not have a policy specific to bowel and bladder management.
Failure to Perform Hand Hygiene During Wound and Skin Care
Penalty
Summary
Facility staff failed to ensure proper hand hygiene during care of a resident with suspected infected lower extremities. During an observation, two staff members entered the room of a resident who had reported weeping and hot lower legs. One staff member removed the TED hose from the resident’s left leg, noted that the leg was hot to the touch and weeping edema fluid, then moved directly to the right leg, removed the TED hose, and assessed that leg without changing gloves or performing hand hygiene between contact with the weeping left leg and the intact right leg. This same staff member later stated she believed she had completed all hand hygiene opportunities but realized, when questioned, that she had moved from one leg to the other without performing hand hygiene. The resident had been started on Cipro for cellulitis on the morning of the observation. A second staff member returned to the room with new TED hose and socks, donned gloves, and assisted with applying the TED hose. This staff member applied TED hose to the resident’s left leg, observed weeping fluid from the skin, and then proceeded to clean up the room while still wearing the same contaminated gloves. While gloved, she touched the resident’s food on the bedside table, handled the resident’s pillow and placed it on the chair where the resident was sitting, and put her gloved hand into her clothing pocket to turn off her ringing cell phone. She did not perform hand hygiene or change gloves after contact with bodily fluids and before touching other items in the room. After leaving the room, she stated she had not thought about performing hand hygiene after finishing application of the TED hose. The facility’s hand hygiene policy required hand hygiene after handling contaminated objects, when moving from a contaminated site to a clean body site during resident care, and after handling items potentially contaminated with blood or bodily fluids.
Failure to Protect Residents From Sexual and Physical Abuse by Other Residents
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from abuse, including sexual and physical abuse, by other residents. In one incident, a resident without capacity to consent was found in a common area with another resident’s hand inside her brief up to the wrist. Staff immediately separated the residents, and the incident was reported to the State Survey Agency; however, the facility’s investigation did not include interviewing or assessing other residents who might have been present or potentially affected by similar sexual abuse incidents. A staff member also reported that the incident was initially reported under the wrong license type because they were unaware the facility held both an adult day care and a skilled nursing facility license. In a separate incident, a resident became upset with his spouse, also a resident, during dinner and shook her head to wake her, then later sprayed water in her face with a spray bottle after staff had intervened and moved her to the nurses’ station. The spouse became agitated by these actions. Observations showed that the couple continued to share a room, with both residents’ nameplates and belongings present. Staff interviews indicated that the spouse who was the target of the behavior was usually kept out of the room and spent most of her time and slept in common areas or by the nurses’ station due to ongoing behaviors between the two. The care plan for the spouse reflected that she was not to be in the room when her husband was present unless both wanted to be there, and staff were to intervene if yelling occurred, based on the prior incident of head shaking and use of the spray bottle.
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