Pioneer Care And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Dillon, Montana.
- Location
- 200 N Oregon St, Dillon, Montana 59725
- CMS Provider Number
- 275124
- Inspections on file
- 27
- Latest survey
- December 31, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Pioneer Care And Rehabilitation during CMS and state inspections, most recent first.
A resident with dementia repeatedly entered other residents' rooms, resulting in a physical altercation and ongoing aggressive behaviors, despite being on increased supervision and residing in a secured memory care unit. Staff documented multiple incidents of wandering, aggression, and mishandling of personal items, indicating that adequate supervision and necessary services were not consistently provided.
A resident with dementia and limited safety awareness, who was at risk for falls and receiving psychotropic medication, experienced multiple unwitnessed falls after an increase in Ativan dosage. The care plan included only minimal fall interventions, and the facility did not adequately assess or address the impact of the medication change, resulting in repeated falls and a fractured hip.
A resident with ongoing symptoms of headache, nausea, and bradycardia did not receive timely medical attention due to the medical director's lack of responsiveness to nursing staff requests. Staff reported difficulty reaching the medical director, who was rarely present and often did not return calls, resulting in delayed care and the resident requiring emergency room intervention.
The facility did not maintain an effective antibiotic stewardship program, failed to ensure timely medication delivery and drug regimen reviews, and lacked an updated QAPI plan. Staff had to obtain medications from a local store due to pharmacy issues, and no gradual dose reductions for psychotropic medications were completed. The infection preventionist role was unfilled by a certified individual, and the QAPI plan had not been reviewed or updated in over two years.
The facility did not have a qualified infection preventionist responsible for the infection prevention and control program. Documentation failed to identify a certified staff member in this role, and a staff member confirmed that the previous infection preventionist had left and the new hire was still in training.
Several residents had incomplete or improperly executed POLST forms, with missing required signatures, names, or dates, and in some cases, forms were left invalid according to state requirements. Staff interviews revealed delays and misunderstandings about the validity of unsigned forms. Additionally, a resident's code status was inconsistently documented across the POLST, physician orders, and daily nursing reports, with confusion regarding the authority of the resident's representative to make healthcare decisions.
The facility did not ensure that a licensed pharmacist consistently performed and documented monthly medication regimen reviews for residents on psychotropic medications. In one case, a resident's medication review omitted a prescribed drug and lacked documentation of the risks and rationale for continued use, while other residents' reviews were missing entirely due to issues with a previous pharmacy provider. Staff reported that inappropriate medication use contributed to a resident's fall and injury.
A resident received multiple overlapping antibiotics for UTIs and sinusitis over several months, with two antibiotics given simultaneously for the same infection and changes in therapy lacking documented rationale. The facility lacked infection tracking and an infection preventionist, and the resident developed C. difficile and persistent ESBL-positive UTIs during this period.
The facility did not report allegations of resident-to-resident abuse and two injuries of unknown origin, including a major injury, to the State Survey Agency as required. In one case, a resident had unexplained bruising and later sustained a fractured hip after an unwitnessed fall, with neither incident reported. In another case, two residents were involved in an alleged physical altercation, but the event was not reported after the facility determined it was not abuse.
A resident was discharged AMA without comprehensive discharge planning, proper documentation of education on risks, or provider notification. The care plan was updated only shortly before discharge, and required notifications and documentation were incomplete, contrary to facility policy.
A resident who was transferred to the hospital did not receive the required transfer discharge notice or bedhold documentation. Staff confirmed the absence of these documents and acknowledged ongoing problems with providing them, and record review showed no evidence of the required forms in the resident's file.
A resident was admitted without a completed baseline care plan within 48 hours, as required. The care plan lacked essential information such as code status, active diagnoses, and risks related to dementia, weakness, and psychotropic medication use. Signature sections for both the resident/representative and staff were left blank, and staff interviews revealed confusion about the care planning process and access to care information.
A resident with a history of needing adaptive utensils and a walled plate for eating did not consistently receive these items or adequate staff assistance during meals. Observations showed the resident struggling to feed herself, with meals left uneaten and difficulty using standard utensils and cups. Staff confirmed that adaptive equipment was not reordered after a recent hospitalization, and the care plan lacked specific interventions, resulting in unmet ADL needs.
A resident with recent hospitalizations and new need for eating assistance was left without help during meals, resulting in minimal food intake despite documentation showing otherwise. Over several months, the resident experienced severe weight loss, with repeated but unaddressed concerns about possible errors in weight measurements. The facility did not ensure accurate monitoring of nutritional intake or resolve discrepancies in weight documentation.
A resident with a recent history of respiratory issues experienced chest pain and worsening breathing difficulties over several days. Despite staff raising concerns and contacting the physician call center, there was a significant delay in obtaining new orders, and the resident's oxygen saturation continued to decline. The resident was ultimately transferred to the hospital for acute on chronic hypoxic respiratory failure.
A resident received more pain medication than prescribed due to inadequate monitoring, incomplete documentation, and inconsistent medication administration practices. Staff were not fully trained on facility-specific medication protocols, and the resident's pain management regimen was changed multiple times without proper oversight, resulting in adverse effects and hospitalization.
A resident experienced increased confusion after being found with two 50mcg Fentanyl patches applied, contrary to medication orders that specified using either one 50mcg patch or two 25mcg patches only if the 50mcg patches were unavailable. The error resulted from unclear communication of the conditional order, leading to improper administration.
Licensed staff repeatedly left medication carts unlocked and unattended in various areas, with pill packets exposed and drawers open. In one case, a staff member accessed the narcotics log book and controlled substance drawer from an unlocked cart and left them open while administering a controlled medication, only securing them after being prompted by a surveyor.
Staff did not perform hand hygiene during medication administration, including before and after giving an insulin injection. Two residents requiring enhanced barrier precautions for wounds did not have appropriate signage or supplies at their doors, and staff interviews revealed confusion about precaution protocols.
The facility did not ensure staff received adequate training on abuse identification and reporting, resulting in missed investigations and failure to report incidents involving two residents—one with unexplained bruising and another involved in a physical altercation. Documentation of abuse training was incomplete, and required reporting procedures were not consistently followed.
The facility failed to encourage residents to report concerns without fear of retaliation, leading to increased anxiety and depression among residents. The new administration, which began in December 2024, was associated with high staff turnover and unresolved issues, causing residents to isolate themselves and avoid activities. Staff noted negative interactions between the administrator and residents, contributing to the residents' dissatisfaction and fear.
A facility failed to provide consistent access to physician-ordered Methadone for a resident, resulting in multiple missed doses. The resident, who was transitioning from Requip to Methadone for restless leg syndrome, experienced medication unavailability due to insurance issues. Staff interviews revealed frequent medication shortages and inadequate pharmacy support. The resident's care plan lacked documentation for managing restless leg syndrome or addressing the missing medications.
A resident with difficulty swallowing was hospitalized for aspiration pneumonia after staff failed to administer medications in crushed form as ordered. Staff relied on incorrect documentation and did not verify medication orders, leading to the resident receiving whole pills. The resident became unresponsive after medication administration, and emergency services found partially dissolved pills in her oropharynx.
A staff member failed to adhere to infection control procedures by assisting a resident in transferring ice from one container to another, leading to cross-contamination when the drink was handed to another resident. This practice was not observed during routine audits, despite being against the facility's food safety policy.
A resident with a history of elopement attempts was not timely evaluated for elopement risk, leading to an elopement incident where the resident took a staff member's car and was involved in an accident. The facility failed to ensure staff were aware of the resident's elopement risk, and the dining room door did not alarm due to the resident removing the Wander guard. The unsecured courtyard and gate facilitated the resident's exit, resulting in hospitalization for injuries.
The facility failed to identify the root cause of falls and implement individualized interventions for two residents, leading to multiple falls and injuries. Staff were unaware of specific fall prevention measures, and care plans were not updated to reflect residents' increased risks and cognitive limitations.
The facility failed to follow prescribed diet textures for two residents, leading to choking episodes and potential risks, and did not adhere to a low carbohydrate diet with double protein for another resident, resulting in increased blood sugar levels and concerns about delayed healing and discharge.
The facility failed to store food in accordance with professional standards by not labeling and dating food items stored in the freezer. Items such as waffles, fish sticks, sliced meat, and shredded/chopped meat were found without proper labeling and dating, contrary to the facility's guidelines.
The facility failed to maintain a clean, well-maintained, and safe environment for its residents. Observations revealed dirty linens, unclean bathrooms, damaged doorknobs, and hazardous baseboard heaters. Maintenance and housekeeping procedures were not consistently followed, leading to these deficiencies.
The facility failed to update care plans for three residents, leading to continued behaviors and repeated falls. One resident had 44 documented behavioral incidents without new interventions, another had eight falls in seven weeks with no care plan updates, and a third had 17 falls over five months with no root cause analysis or updated interventions. Staff interviews revealed that care plans were not consistently reviewed or updated, and communication relied on verbal reports rather than systematic documentation.
The facility failed to ensure a resident's dignity and clean appearance by not providing necessary assistance during meals. A resident was observed struggling to eat, resulting in food debris on his clothing and the floor. Despite other residents using clothing protectors, this resident was not offered one, even though his care plan indicated a decline in functional abilities.
The facility failed to provide necessary behavioral health services for two residents with documented behavioral concerns. One resident had a moderate depressive disorder and exhibited concerning behaviors without receiving mental health evaluations. Another resident displayed frequent behavioral issues, including aggression and yelling, but had no referrals for mental health services despite numerous documented incidents.
The facility failed to provide medical social services for a resident with behavioral concerns. A staff member without a degree admitted to learning on the job and stated that medication changes had not helped the resident's behaviors. No mental health or behavioral health notes, referrals, or counseling were documented, despite 44 incidents of documented behaviors.
A resident with hemiplegia and muscle weakness experienced a 47-day delay in receiving physical therapy services due to the facility's lack of a physical therapist. The resident was making progress in walking before admission, but the delay hindered their ability to stand and pivot. Staff interviews confirmed the absence of a physical therapy program for the past four years.
The facility failed to offer pneumococcal vaccinations to a resident. The resident's medical record showed no evidence of receiving or declining the vaccination. A staff member was waiting for ImMTrax login credentials to verify vaccination status and needed to discuss vaccinations with the resident's POA.
The facility failed to offer COVID-19 vaccinations to a resident, as their medical record did not show any documentation of receiving or declining the vaccination. Staff indicated they were waiting for ImMTrax login credentials and needed to discuss vaccinations with the resident's POA.
Failure to Prevent Resident with Dementia from Entering Other Residents' Rooms
Penalty
Summary
The facility failed to provide necessary services and supervision to a resident diagnosed with dementia who repeatedly entered other residents' rooms, resulting in a physical altercation and minor injuries to another resident. Despite being known to wander and having a history of confusion regarding his own room, the resident continued to access other residents' rooms even after being placed on 1-to-1 observation, then fifteen-minute checks, and eventually residing in a secured memory care unit. Staff interviews and nursing progress notes documented multiple incidents where the resident was redirected after entering other rooms, displaying aggressive behavior, and taking or mishandling other residents' personal items. The facility's policy required appropriate treatment and services for residents with dementia to ensure their highest practicable well-being. However, documentation showed that the resident continued to wander into other rooms and engage in disruptive and aggressive behaviors, including taking items and attempting to dispose of them inappropriately, despite interventions. The facility did not consistently ensure adequate supervision to prevent these incidents, placing both the resident and others at risk for further altercations.
Failure to Prevent Falls in Resident Receiving Psychotropic Medication
Penalty
Summary
The facility failed to identify and implement effective interventions to prevent further falls for a resident with dementia, limited safety awareness, and a known risk for falls. The resident was prescribed psychotropic medications, specifically Ativan, which was recently increased in dosage. Despite the resident's history and increased risk, the care plan contained only minimal fall interventions. The resident experienced multiple unwitnessed falls, including one resulting in head lacerations, and the facility's investigation did not consider the recent increase in Ativan dosage as a contributing factor. Subsequent documentation showed that the resident continued to have increased falls after the Ativan dose was raised, ultimately sustaining a fractured hip. Staff interviews confirmed that the Ativan contributed to the resident's falls and that the medication was not appropriate for the resident's needs. The decrease in Ativan dosage occurred only after the resident had already suffered a serious injury. The facility's lack of comprehensive assessment and timely intervention in response to the resident's changing condition and medication regimen led to repeated falls and significant harm.
Failure to Ensure Effective Medical Director Coordination and Timely Response
Penalty
Summary
The facility failed to ensure that the medical director effectively coordinated medical care, as evidenced by a lack of timely response to nursing staff requests for direction regarding a resident's care. One resident experienced ongoing symptoms, including a severe headache, nausea, and persistent bradycardia, with documented pulse rates as low as 44 beats per minute over several days. Despite repeated attempts by nursing staff to contact the medical director about the resident's slow pulse, calls were not returned promptly, and the resident's condition was not addressed in a timely manner. Interviews with staff revealed that the medical director was only present at the facility once per month and was difficult to reach, with calls often going unanswered for several days. The process for addressing concerns with the medical director's performance was lacking, and there was no established method for managing issues related to the medical director's care of residents. Ultimately, the resident required emergency room care, where new medical orders were provided, including discontinuation of a medication and referral to a cardiologist.
Failure to Maintain Antibiotic Stewardship, Medication Management, and QAPI Program
Penalty
Summary
The facility failed to maintain an effective antibiotic stewardship program and did not ensure the pharmacy delivered medications or completed monthly drug regimen reviews for all residents over a one-year period. Staff reported that medications were not being received as ordered, leading them to obtain medications from a local store when the pharmacy could not supply them. Additionally, drug regimen reviews were inaccessible due to issues with the pharmacy's portal, resulting in no gradual dose reductions for psychotropic medications during the specified timeframe. The facility continued to use the same pharmacy until a new contract could be established, despite these ongoing issues. The facility also lacked a current and updated QAPI (Quality Assurance and Performance Improvement) plan, with the last documented goal dates over two years old. The infection preventionist role was not being fulfilled, as the previous staff member did not complete required duties and the newly hired nurse was not yet certified in infection prevention. QAPI activities were based on survey citations, grievances, and observations, but the plan had not been reviewed or revised in over two years. Staffing challenges were also noted, with one staff member working 11 consecutive days without a day off.
Lack of Designated Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified infection preventionist to oversee the infection prevention and control program. During review of the entrance conference materials, there was no documentation provided to show that a staff member held an infection preventionist certificate or was responsible for the infection control program. In an interview, a staff member confirmed that there was no current staff member with infection preventionist certification, as the previous infection preventionist was no longer employed and the newly hired individual was still completing infection preventionist training.
Deficient Completion and Implementation of POLST Forms and Inconsistent Code Status Documentation
Penalty
Summary
The facility failed to ensure the timely and complete execution of Provider Orders for Life-Sustaining Treatment (POLST) forms for several residents. Specifically, for three residents, the POLST forms were missing required signatures, printed names, or dates in mandatory sections, including the absence of the resident or responsible party's signature and the physician's signature and date. In one case, the form was signed by a physician without verification of who was making life-sustaining choices for the resident. In another, the physician did not print their name or fill in the date, and in a third, the mandatory physician signature and date were left blank, rendering the form invalid according to Montana state requirements. Staff interviews revealed that the process for obtaining physician signatures could be delayed by up to a month, and there was a misunderstanding among staff regarding the validity of unsigned POLST forms. Additionally, the facility failed to ensure consistency in documenting a resident's code status. For one resident, the POLST indicated a Do Not Resuscitate (DNR) status, while physician orders and admission paperwork reflected a full code status, with conflicting information about the authority of the resident's representative to make healthcare decisions. The daily nursing report listed the resident as DNR, but the physician had changed the code status based on the representative's input, despite the representative only having financial, not healthcare, power of attorney. These deficiencies demonstrate lapses in the facility's processes for accurately documenting and implementing residents' treatment preferences and code statuses.
Failure to Ensure Adequate Monthly Pharmacist Medication Reviews and Documentation
Penalty
Summary
The facility failed to ensure that a licensed pharmacist adequately performed and documented monthly medication regimen reviews for several residents receiving psychotropic medications. For one resident, the pharmacist's review did not include all prescribed medications, specifically omitting Ativan, and lacked documentation of the risks versus benefits or rationale for continued use of psychotropic drugs. The physician declined a gradual dose reduction without providing clinical justification, and the resident continued on multiple psychotropic medications for extended periods without documented attempts at dose reduction. Staff interviews revealed concerns that the use of Ativan contributed to the resident's falls, including a hip fracture. Additionally, the facility was unable to provide monthly pharmacist medication regimen reviews for several other residents over the past year. This was attributed to issues with a previous pharmacy provider, which resulted in the facility being locked out of the system and unable to access historical documentation, including pharmacy reviews and recommendations. As a result, there was no evidence that appropriate monthly reviews or recommendations were completed to ensure residents were receiving suitable medications and dosages for their diagnoses.
Failure to Monitor and Appropriately Administer Antibiotics
Penalty
Summary
The facility failed to ensure appropriate antibiotic use and infection control for a resident, resulting in prolonged and overlapping antibiotic therapy without adherence to accepted standards. The resident was prescribed multiple antibiotics over several months, including Bactrim, Vancomycin, Ciprofloxacin, Macrobid, and Cefdinir, often for urinary tract infections (UTIs) and sinusitis. There were instances where two different antibiotics were administered simultaneously for the same UTI, and changes in antibiotic regimens were made without documented rationale. The resident's medication administration records showed overlapping courses and incomplete documentation regarding discontinuation and switching of antibiotics. Additionally, the facility did not have an infection preventionist at the time of the survey, and infection tracking was not performed as required. Staff were unaware of the resident receiving two antibiotics concurrently for the same infection. The resident repeatedly tested positive for Escherichia coli/Extended Spectrum Beta Lactamase (ESBL) in urine cultures and contracted Clostridium difficile during this period. These findings indicate a lack of oversight and monitoring of antibiotic use and infection control practices for the resident involved.
Failure to Timely Report Alleged Abuse and Injuries of Unknown Origin
Penalty
Summary
The facility failed to report allegations of resident-to-resident abuse and injuries of unknown origin to the State Survey Agency as required. In one instance, a resident was found to have fading bruising on the left lower back with no documented falls or injuries in the preceding weeks, and the cause of the bruising was not identified. Staff were unaware of the bruising, no investigation was completed, and the incident was not reported as required. Later, the same resident sustained a fractured hip after a fall that was not witnessed, and the resident was an unreliable reporter. This major injury of unknown origin was also not reported to the State Survey Agency. In another case, a resident was agitated and allegedly hit her roommate, as reported by the roommate, though the incident was not witnessed by staff. The facility investigated the event but determined it was not abuse and did not report the allegation to the State Survey Agency. The facility's policy requires all allegations, including those not yet investigated, to be reported to the administrator and the State Survey Agency, but these incidents were not reported in accordance with policy.
Failure to Complete Required Elements for AMA Discharge
Penalty
Summary
The facility failed to ensure all required elements were completed for a resident who was discharged against medical advice (AMA). The resident's care plan did not include discharge planning until three days prior to the AMA discharge, and the only documentation was the resident's wish to return to the community. There was no evidence of comprehensive discharge planning, education on the risks of leaving AMA, or documentation of provider notification. The only education documented was that the facility could not provide medications to take upon discharge. There was also no record of the provider being notified, no recapitulation of the resident's stay, and no documentation of contact with other entities regarding the risks associated with the AMA discharge. A review of the AMA release form showed it was signed by the nurse and the resident, but lacked a second witness signature and only included a brief handwritten note about the resident's departure. Staff interviews confirmed that education and family contact occurred but were not documented. The facility's policy requires informing the resident and family of risks, notifying the physician, and documenting these actions, none of which were fully completed or documented in this case.
Failure to Provide Transfer Discharge Notice and Bedhold Documentation
Penalty
Summary
The facility failed to provide the required transfer discharge notice and bedhold documentation to a resident who was transferred to the hospital. During an interview, a staff member confirmed that the transfer discharge notice was not present for the resident and acknowledged ongoing issues with providing these notices and bedhold forms. Record review showed that the resident was hospitalized for a period, but there was no documentation of a transfer discharge notice or bedhold form in the resident's record.
Failure to Complete and Implement Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for one resident. The baseline care plan did not identify the resident's code status, omitted active diagnoses contributing to admission, and failed to address risks associated with dementia, weakness, and the use of psychotropic medications. Additionally, the care plan incorrectly indicated no history of falls and lacked a completion date. Required signature sections for both the resident/representative and staff were left blank. Interviews with staff revealed uncertainty about the care planning process and how information from the baseline care plan was communicated to certified nursing assistants (CNAs). Some staff were unaware of how to access the baseline care plan, and one staff member stated that the only care information available was a sheet completed by the DON. The lack of a completed evaluation and missing staff signatures contributed to the incomplete baseline care plan.
Failure to Provide Needed ADL Assistance and Adaptive Equipment During Meals
Penalty
Summary
A deficiency occurred when the facility failed to review and provide the necessary assistance and adaptive equipment for a resident requiring help with activities of daily living (ADLs) during meals. The resident, who had a history of using adaptive utensils and a walled plate due to difficulty handling standard silverware, reported that staff did not feed her properly and that adaptive equipment was not consistently provided. Observations showed the resident struggling to eat independently, unable to grasp food items, and having difficulty using regular utensils and cups without lids, resulting in minimal food and fluid intake during meals. Staff interviews confirmed that adaptive equipment had not been reordered after the resident's recent hospitalization, and the care plan only indicated assistance with eating without specifying the need for adaptive devices. Further observations revealed that meals were left uneaten, and the resident continued to have trouble feeding herself due to the lack of appropriate adaptive equipment and staff assistance. Staff acknowledged that therapy had previously worked with the resident on meal-related ADLs and that she was supposed to receive specific adaptive items and feeding assistance, but these interventions were not consistently implemented after her return from the hospital. The facility did not identify or address the resident's ongoing difficulties with eating, resulting in a failure to ensure she maintained her ability to perform this ADL.
Failure to Accurately Monitor Meal Intake and Address Weight Measurement Errors
Penalty
Summary
The facility failed to accurately monitor and document a resident's meal intake and feeding abilities, as well as address suspected errors in weight measurements, in the context of a resident experiencing severe weight loss. Observations showed that the resident, who had recently returned from two hospitalizations and now required supervision or assistance with eating, was left alone in bed with a meal tray placed out of reach and without any setup or assistance. The resident struggled to feed himself and ultimately consumed very little of his meal, despite documentation indicating he had eaten 76-100% of his lunch. This pattern of inaccurate meal intake documentation was noted over several days. Additionally, the resident's weight records over several months showed a significant and steady decline, amounting to an 11.59% loss over three months. Nutrition notes repeatedly identified possible errors in weight measurements and called for reweighs to verify accuracy, but these discrepancies were not resolved over a six-month period. The resident's weight loss was being monitored, and while some weight loss was considered desirable due to the resident's BMI, the facility did not ensure accurate monitoring of food intake or address ongoing concerns about the accuracy of weight measurements.
Delayed Physician Response to Respiratory Distress and Chest Pain
Penalty
Summary
A resident with a recent history of hospitalization for breathing difficulties experienced chest pain and respiratory concerns over a period of several days. Nursing progress notes indicated that concerns about chest pain were raised by respiratory therapy and the unit manager, and a call was placed to the physician call center. However, there was a significant delay in obtaining new physician orders, with no new orders documented until 19 hours after the initial concern. During this time, the resident continued to exhibit symptoms such as low oxygen saturation, a wet/loose cough, and pleural rub sounds, with oxygen saturation levels dropping as low as 86% on prescribed oxygen. Despite ongoing communication among staff regarding the resident's deteriorating condition, including further drops in oxygen saturation and continued respiratory distress, there was no timely follow-up from the physician. The resident's condition worsened, and he was eventually transferred to the hospital by ambulance after his oxygen saturation fell to 79% while on oxygen. Hospital records confirmed the resident was admitted for acute on chronic hypoxic respiratory failure and other related complications.
Failure to Provide Safe and Effective Pain Management
Penalty
Summary
The facility failed to provide effective pain management and monitoring for a resident, resulting in the administration of more medication than prescribed. Staff interviews and record reviews revealed that the narcotics log book did not accurately reflect the number of fentanyl patches administered, and there was a lack of clear documentation regarding the application, removal, and effectiveness of the patches. Staff members were not fully trained on the facility's medication management process, and one staff member admitted to following procedures from previous employment rather than facility-specific protocols. Additionally, there was no documentation to ensure that the fentanyl patches were in place for the correct duration, nor was there evidence of monitoring for adverse reactions or effectiveness. The resident experienced unmanaged pain, leading to multiple changes in pain medication, including the discontinuation of Norco, initiation of fentanyl patches, and subsequent switches between different dosages and types of pain medications. The medication administration record showed that acetaminophen was given in excess of the prescribed daily limit on one occasion. Progress notes indicated the resident became increasingly lethargic, unarousable, and cold to the touch, ultimately requiring transfer to the emergency room, where a reaction to medication was suspected. The lack of consistent monitoring and documentation contributed to the resident receiving more medication than prescribed and experiencing adverse effects.
Significant Medication Error Due to Misapplied Fentanyl Patch Orders
Penalty
Summary
A significant medication error occurred when a resident was found to have two 50mcg Fentanyl patches applied, despite medication orders specifying the use of either one 50mcg patch or two 25mcg patches only if the 50mcg patches were unavailable. The resident subsequently exhibited increased confusion, including not recognizing her husband and displaying unusual behavior at mealtime. Review of the medication administration record showed the order for two 25mcg patches was only documented as given once, with all other opportunities marked as not applicable, while the 50mcg patch was the standard order. The medication orders were entered with the expectation that staff would understand the conditional use of the two 25mcg patches, but this was not clearly communicated, leading to the error.
Medication Carts Left Unsecured and Unattended
Penalty
Summary
Licensed staff failed to ensure that medication carts were secured and locked when unattended. Multiple observations revealed that medication carts were left unlocked in various locations, including in front of the main nursing desk, in the dining room, and in hallways, with no staff present. On several occasions, pill packets were visibly hanging out of the carts, and drawers were left open. In one instance, a nurse was away from the cart while administering medications, leaving the cart out of sight and unsecured. During another observation, a staff member accessed the narcotics log book and the controlled substance drawer from an unlocked cart, and then left the cart and drawer open while preparing to administer a controlled medication. The staff member asked the surveyor to watch the open cart and controlled medication drawer while they attended to medication administration, only locking the cart and drawer after being prompted by the surveyor. These actions resulted in medications, including controlled substances, being left unsecured and accessible when staff were not present.
Failure to Follow Hand Hygiene and Enhanced Barrier Precautions
Penalty
Summary
Staff failed to follow proper hand hygiene protocols during medication administration, as observed when two staff members did not perform hand hygiene before or after passing medications, including administering an insulin injection. Additionally, the facility did not implement enhanced barrier precautions for two residents: one resident with an unstageable wound connected to a wound vac had no signage or supplies indicating the need for enhanced barrier precautions, and another resident with a physician order for enhanced barrier precautions also lacked appropriate signage and supplies at the door. Interviews with staff confirmed a lack of clarity and adherence to precaution protocols for these residents.
Inadequate Staff Education and Failure to Investigate or Report Abuse Allegations
Penalty
Summary
The facility failed to provide adequate abuse education to administrative staff, resulting in insufficient knowledge regarding the identification and management of abuse allegations, particularly for residents with cognitive deficits. In one instance, a resident with cognitive impairment was found to have scattered, healing bruises on the lower back, accompanied by pain. Nursing notes indicated no falls or injuries during the relevant period, and no investigation was conducted to determine the cause of the bruising. The administrative staff member responsible for abuse investigations was not notified of the incident and had not completed an investigation at the time of the survey. In another case, a resident became agitated and threatened physical harm to a roommate, ultimately hitting the roommate, though the incident was not witnessed. The event was investigated as abuse, but the allegation was not reported as required. The staff member involved had not received abuse training from the facility, and there was uncertainty regarding the training provided by the staffing agency. Documentation of abuse and neglect training for staff was incomplete, with missing dates and unclear instructor qualifications. The facility's policy required reporting of abuse allegations, but this was not consistently followed.
Residents Fear Retaliation Under New Administration
Penalty
Summary
The facility failed to ensure that services were administered in a manner that encouraged residents to report concerns or complaints without fear of retaliation. This deficiency was observed in four of the fourteen sampled residents. The residents expressed concerns about the new administrator's actions and the overall management of the facility, which led to increased anxiety, depression, and isolation among them. Residents reported a decline in morale and a reluctance to participate in activities or eat meals in the dining room. Interviews with residents revealed that the new management, which began in December 2024, was associated with a high turnover rate of staff and unresolved issues raised during resident council meetings. One resident expressed concerns about potential retaliation if they voiced their complaints, while another resident reported increased depression and anxiety, spending more time isolated in their room. The residents' mood assessments indicated a consistent level of depression, with some residents experiencing increased symptoms since the new administrator's arrival. Staff interviews corroborated the residents' concerns, noting that the new administrator's interactions with residents were not positive and that there was an increase in resident behaviors and depression. Staff members observed that some residents were isolating themselves more frequently and not participating in activities. There were also reports of management staff threatening residents with eviction due to their behavior, further contributing to the residents' fear of retaliation and dissatisfaction with the facility's administration.
Medication Availability Deficiency
Penalty
Summary
The facility failed to consistently provide physician-ordered medications for a resident, leading to missed doses of Methadone. The resident, who was being tapered off Requip for restless leg syndrome and switched to Methadone, experienced several instances where the medication was unavailable due to insurance not covering the cost. Staff interviews revealed that the facility had planned to consult with the provider to find an alternative medication covered by insurance, but in the meantime, the facility was paying for the Methadone. Despite these efforts, the resident missed 22 out of 29 scheduled doses in January and 4 out of 19 in February. Interviews with staff members indicated that the facility frequently faced issues with medication availability, and the pharmacy was not helpful in resolving these issues. The facility had conducted an investigation for drug diversion due to missing medications but found no evidence of diversion. Additionally, the resident's care plan did not address the issues related to restless leg syndrome, the use of Methadone, or the missing medications, which meant that staff did not have documented interventions to offer alternate solutions for the resident's condition.
Failure to Administer Crushed Medications Leads to Aspiration Pneumonia
Penalty
Summary
The facility failed to administer medications as ordered by the physician for a resident with a diagnosis of difficulty swallowing, leading to a significant medication error. The resident was supposed to receive medications in a crushed form due to her swallowing difficulties, but staff members administered them whole. This oversight resulted in the resident being transferred to the emergency department and subsequently hospitalized for aspiration pneumonia. Interviews with various staff members revealed a lack of awareness and adherence to the specific medication orders for the resident. A travel nurse and other staff members relied on a document at the nurse's station that incorrectly indicated the resident's medications should be given whole. Despite the resident's known history of swallowing difficulties, staff members did not verify the medication orders and continued to administer the medications whole, assuming the resident would refuse crushed medications. The incident occurred when a staff member administered the resident's medication in applesauce, after which the resident began coughing and became unresponsive. Emergency medical services were contacted, and upon arrival at the hospital, the resident was found to have partially dissolved pills and possibly food in her oropharynx. The resident was diagnosed with severe sepsis, acute on chronic respiratory failure, and aspiration pneumonia, with evidence of food and pill material in her lungs.
Infection Control Breach During Drink Service
Penalty
Summary
The facility failed to ensure proper infection control procedures were followed during drink service, leading to a potential spread of infectious pathogens. During an observation, a resident was seen removing ice with a spoon from her drinking container and placing it into a cup of coffee. Staff member C assisted the resident in this process and then handed the coffee cup to another resident, resulting in cross-contamination. Staff member C admitted to not realizing the cross-contamination had occurred. Staff member G, who conducts weekly audits during meal service, stated that it is not acceptable practice to assist residents in sharing ice cubes. However, she had not observed this practice during her audits. The facility's undated policy on Food Safety Requirements specifies that foods and beverages should be distributed and served in a manner that prevents contamination.
Failure to Manage Elopement Risk Leads to Resident Injury
Penalty
Summary
The facility failed to manage a resident with a known history of elopement attempts, resulting in the resident eloping, sustaining an injury, and being hospitalized. The resident, who had a dementia diagnosis and poor safety awareness, was not evaluated timely for elopement risk throughout his stay. Despite multiple incidents indicating the resident's intent to leave the facility, such as packing belongings and attempting to leave, the facility did not conduct a new elopement assessment after an elopement incident on 8/12/24. A Wander guard was not issued until 8/13/24, and the resident continued to remove it, with no additional interventions implemented to prevent tampering. The facility also failed to ensure staff were adequately informed of the resident's elopement risk. Staff interviews revealed a lack of awareness and understanding of which residents were at risk for elopement and how to identify them. The facility's policy required a systematic approach to monitoring and managing residents at risk for elopement, including staff awareness and communication of interventions, but this was not effectively implemented. Staff were unsure how to identify residents at risk and relied on inconsistent methods to determine if a resident was an elopement risk. The incident culminated in the resident eloping from the facility, taking a staff member's car, and being involved in a vehicle accident. The dining room door, which should have alarmed if a resident with a Wander guard attempted to exit, did not alarm because the resident had removed the Wander guard. The unsecured courtyard and gate facilitated the resident's exit. The resident was found later with injuries and was hospitalized for monitoring. The facility's failure to evaluate the resident's elopement risk timely and ensure staff awareness of the risk contributed to the resident's elopement and subsequent injury.
Failure to Implement Individualized Fall Prevention Interventions
Penalty
Summary
The facility failed to identify the root cause of falls and implement individualized interventions for two residents, leading to multiple falls and injuries. Resident #42 was observed attempting to stand up from his wheelchair and tripped on the foot pedals, nearly falling. Staff indicated that the resident had already fallen earlier that morning and had a history of frequent falls, especially when he had infections or was on antibiotics. Despite 17 falls in five months, including two that required emergency department visits, the resident's care plan did not reflect his increased risk during infections or his cognitive limitations in calling for help. The care plan interventions were generic and did not address the resident's specific needs or behaviors, such as his impulsivity and confusion about his room change. Staff interviews revealed a lack of documentation and communication regarding fall incidents and interventions. Staff member I admitted that the morning fall of resident #42 had not yet been documented, and new interventions were communicated verbally rather than through updated care plans or Kardex. The facility had also discontinued using fall indicators on resident doors and wheelchairs, citing dignity and HIPAA concerns. Staff members were unaware of any fall prevention committee or specific interventions for high-risk residents, indicating a systemic issue in fall management and prevention. Resident #49 also experienced multiple falls, including one that resulted in a head laceration requiring sutures. Observations showed the resident attempting to stand from her wheelchair without assistance, and staff were not always present to intervene. Despite being assessed as a high fall risk, the resident did not have fall prevention indicators on her wheelchair or door. The facility's fall prevention program, which included placing indicators and updating care plans, was not consistently followed. Staff interviews confirmed a lack of awareness and involvement in fall prevention efforts, further highlighting the facility's failure to provide adequate supervision and individualized care to prevent accidents.
Failure to Follow Prescribed Diet Textures and Controlled Carbohydrate Diet
Penalty
Summary
The facility failed to follow diet textures for two residents, leading to documented choking episodes for one resident and potential choking risks for another. Staff member K prepared meals that did not meet the prescribed Soft and Bite-Sized texture, cutting meat with a knife and serving a ham sandwich, which were not approved by the speech therapist or physician. The speech therapy notes and diet orders for both residents specified the need for Soft and Bite-Sized foods, but these were not adhered to during meal preparation, as observed and confirmed by staff interviews and document reviews. Additionally, the facility did not follow a low carbohydrate diet with double portions of protein for another resident, resulting in increased blood sugar levels and concerns about delayed healing and discharge. The resident reported receiving meals high in carbohydrates and lacking the prescribed double protein. Staff interviews revealed that the kitchen used diet cards to guide meal preparation, but these were not consistently followed, leading to the resident's elevated blood sugar levels and lack of necessary protein for healing. Review of the resident's electronic medical record showed significant fluctuations in blood sugar levels, with no notes from a dietician to address these issues. The facility's document on Controlled Carbohydrate Diet emphasized the need for individualized evaluation of blood glucose responses, but this was not reflected in the resident's care. The failure to adhere to prescribed diets and textures posed significant health risks to the residents involved.
Failure to Label and Date Food in Freezer
Penalty
Summary
The facility failed to store food in accordance with professional standards by not labeling and dating food items stored in the freezer. During an observation, several items were found in the freezer that were not in their original containers and lacked proper labeling and dating. These items included a bag of waffles, an open bag of fish sticks, a package of sliced meat, and a package of shredded/chopped meat. The facility's guidelines require that frozen foods be labeled with a 'use by' date 45 days after opening, but this was not adhered to in these instances.
Failure to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to provide a clean, well-maintained, and safe environment for its residents. Observations revealed that several residents had visibly dirty linens, with one resident stating that their sheets were only changed once a week and sometimes had to request changes due to the dirtiness. Another resident had a betadine stain on their linens that had been there for two weeks. Additionally, the CNA classroom toilet was observed to have urine stains and a brownish stain inside the bowl, and the bathroom floor was also stained. The doorknob in one resident's room was falling apart, and the baseboard heaters in the dining area and halls were damaged, with sharp metal pieces sticking out, posing a safety hazard. Maintenance staff were not always aware of these issues, and there was a lack of a consistent system for reporting and addressing maintenance needs. Further observations showed that another resident's bathroom floor was visibly dirty, with a greenish/brown buildup in the toilet bowl. The facility's housekeeping records did not show any reports of the broken baseboard heaters or doorknobs. The facility's housekeeping expectations included daily cleaning of rooms and bathrooms, but these standards were not being met. The facility document titled 'Housekeeping Meeting' outlined detailed cleaning procedures, but the observations indicated that these procedures were not being followed consistently, leading to the deficiencies noted by the surveyors.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to update care plans for three residents, leading to continued behaviors and repeated falls. Resident #36 exhibited 44 documented behavioral incidents over several months, yet his care plan had not been updated with new interventions since the initial revision date. Similarly, Resident #49 experienced eight falls within seven weeks, one of which resulted in a head injury requiring sutures, but no new interventions were added to her care plan. Resident #42 had 17 falls over five months, with a notable pattern of increased falls during infections, but her care plan lacked updated interventions and root cause analysis after the initial implementation date. Interviews with staff revealed that the Assistant Director of Nursing (ADON) was responsible for updating care plans, but nurses were not involved in the revision process. Staff also indicated that care plans were typically revised yearly or more frequently if necessary, but this was not consistently done. The facility relied on verbal reports to communicate new interventions to aides, rather than ensuring all staff reviewed the care plans or Kardex. This lack of systematic updating and communication contributed to the deficiencies observed in the care plans for the three residents.
Failure to Maintain Resident Dignity and Clean Appearance
Penalty
Summary
The facility failed to ensure a resident's dignity and clean appearance by not providing necessary assistance during meals. Resident #42 was observed on two separate occasions struggling to eat, resulting in food debris on his clothing and the floor. Despite other residents using clothing protectors, resident #42 was not offered one. Interviews revealed that the resident had experienced a decline in functional abilities, as indicated in his Significant Change MDS, but the facility did not adjust the care plan to reflect this change and provide the necessary assistance during meals.
Failure to Provide Behavioral Health Services
Penalty
Summary
The facility failed to provide necessary behavioral health services for two residents with documented behavioral concerns. Resident #6 had a PHQ-9 score indicating moderate depressive disorder and a care plan addressing depression related to multiple conditions, including vascular dementia and PTSD. Despite documented behaviors such as exit-seeking, agitation, and suicidal ideation, there were no mental health evaluations or consultations for this resident. Staff interviews confirmed the absence of mental health services for Resident #6, despite several documented incidents of concerning behavior and a request for mental/behavioral health records. Resident #36 exhibited frequent behavioral issues, including yelling, using profanity, and displaying aggression towards other residents. Despite 44 documented incidents of behavioral concerns, there were no referrals or notes for mental health services in the resident's EMR. The care plan for Resident #36 was not initiated until a year after admission and included minimal interventions, such as the addition of Seroquel. Staff interviews confirmed the lack of mental health services for Resident #36, despite ongoing behavioral issues and concerns about the resident's mental health.
Failure to Provide Medical Social Services for Resident with Behavioral Concerns
Penalty
Summary
The facility failed to provide medical social services for a resident with behavioral concerns. During an interview, a staff member who had been employed for about a month and a half admitted to not having a degree and learning on the job. This staff member stated that she intervened when the resident was agitated and had spoken to the doctor about medication changes, which did not help with the resident's behaviors. The staff member also confirmed that there had been no medical social services provided for the resident, and the only changes made were requests for medication adjustments by the doctor. A request for mental health or behavioral health notes, referrals, visits, or counseling revealed that there were no documents available. The resident's electronic medical record (EMR) also lacked notes or referrals for mental health or behavioral health services. A review of the resident's behavior notes showed 44 incidents of documented behaviors over a specified period, including yelling, wanting the police or doctor called, concerns about his brother, refusing outside appointments, agitation, aggression, and anxiety.
Delayed Physical Therapy Services for Post-Stroke Resident
Penalty
Summary
The facility delayed physical therapy services for a post-stroke resident for 47 days after admission. The resident, who had a diagnosis of hemiplegia and hemiparesis following a cerebral infarction, muscle weakness, and repeated falls, was making progress in walking before arriving at the facility. However, due to the absence of a physical therapist at the facility, the initial PT evaluation was not conducted until 47 days post-admission. Interviews with staff revealed that the facility had not had a physical therapy program for the last four years, and the delay in initiating PT was acknowledged as detrimental to the resident's progress in standing and pivoting.
Failure to Offer Pneumococcal Vaccinations
Penalty
Summary
The facility failed to offer pneumococcal vaccinations to a resident. Review of the resident's medical record showed no evidence that the resident had received or declined the pneumococcal vaccination. The resident was admitted to the facility on an unspecified date. During an interview, a staff member stated she was waiting for ImMTrax login credentials to verify vaccination status and needed to discuss vaccinations with the resident's POA.
Failure to Offer COVID-19 Vaccination to Resident
Penalty
Summary
The facility failed to offer COVID-19 vaccinations to one of the five residents sampled for vaccination or declination. Specifically, the medical record of Resident #44 did not show any documentation of receiving or declining the COVID-19 vaccination. Resident #44 was admitted to the facility on an unspecified date. During interviews, a staff member indicated that they were waiting for ImMTrax login credentials to verify vaccination statuses and needed to discuss vaccinations with Resident #44's Power of Attorney (POA).
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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