River Ridge Rehabilitation And Nursing Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Billings, Montana.
- Location
- 1415 Yellowstone River Rd, Billings, Montana 59105
- CMS Provider Number
- 275123
- Inspections on file
- 27
- Latest survey
- January 15, 2026
- Citations (last 12 mo.)
- 29
Citation history
Health deficiencies cited at River Ridge Rehabilitation And Nursing Llc during CMS and state inspections, most recent first.
The facility failed to complete thorough investigations and implement incident-specific interventions following two reported events. In one case, a cognitively impaired resident in a wheelchair was taken outside through an alarmed door by a vendor, preventing the alarm from sounding, and staff were unaware the resident had left until notified by family; the subsequent review focused on door alarms and resident risk factors but did not address the vendor-assisted exit or lack of alarm activation as the root cause. In another case, a resident was found after shift change in urine-soaked clothing and a soiled brief, with the facility later unable to provide complete investigation documentation, interdisciplinary review notes, evidence of staff education, or proof that the resident’s provider and responsible party were notified, contrary to its abuse/neglect policy requiring complete written investigation records and reporting.
A resident eloped from the facility without staff knowledge by exiting through an alarmed door that had been deactivated by a vendor. Following the incident, staff reported that the care plan would be updated after an IDT review, and facility documentation stated the plan would reflect a need for closer monitoring and supervision near exits. However, the actual care plan revision only included adding the resident to an elopement binder, providing education about not leaving without assistance, encouraging use of an enclosed patio, and general wandering/elopement interventions, without specifying closer supervision at exits. This failed to align with the facility’s own elopement policy requiring that risk-related interventions be incorporated into the care plan and communicated to staff.
A resident who required partial/moderate assistance with toileting hygiene and was frequently incontinent of bladder and bowel was found in bed with urine-soaked clothing and a soiled brief after a shift change. Day shift staff discovered the condition while beginning morning care and reported that the off-going night shift staff member, who had been responsible for the resident, did not communicate any need for incontinence care. The resident’s care plan required regular checks for incontinence and prompt peri-care, but this was not carried out, and the facility’s investigation identified a lapse in care by the night shift staff member.
Dietary staff did not consistently wear required hair coverings and beard nets while preparing and serving meals, as observed during multiple meal services. Despite being informed of the policy and ongoing audits, a staff member admitted to frequently forgetting to use the protective attire, resulting in unsanitary food handling conditions.
A resident with significant mobility limitations was left with an as-needed topical medication unsecured at bedside, without proper interdisciplinary assessment for self-administration. Due to the presence of multiple creams on the bedside table, a staff member mistakenly applied the wrong cream, causing the resident temporary discomfort.
A nurse failed to ensure the safe administration of a prescribed topical medication by leaving Triamcinolone Acetonide cream unsupervised at a resident's bedside, resulting in a CNA later applying the wrong cream and causing the resident temporary discomfort. The nurse, new to the facility, did not follow proper procedures for medication administration.
A staff member transferred a resident using a Hoyer lift without the required assistance of a second staff member, despite having received training and education on proper lift protocols. This action was confirmed through interviews and facility documentation, which emphasized the facility's policy requiring two staff for all mechanical lift transfers.
A resident experienced a burning sensation after a staff member applied the wrong topical cream from an unlabeled medication cup left at the bedside. The nurse had placed both the prescribed and an as-needed cream in clear, unlabeled cups without instructions, leading to the error. Facility policy requiring proper medication administration and verification was not followed.
Staff did not follow enhanced barrier precaution protocols during a high-contact transfer of a resident with an indwelling urinary catheter. Two staff members wore gloves but failed to don gowns, resulting in direct contact between their uniforms and the resident. The infection preventionist confirmed that staff are educated to use gowns and gloves for such residents during transfers, as outlined in facility policy.
The facility failed to properly label, date, and store food items in the walk-in cooler and nutrition room refrigerators, leading to potential health risks. Observations revealed unlabeled and expired items, dirty surfaces, and improper temperature monitoring. Staff provided inconsistent information about responsibilities for checking and cleaning the refrigerators, violating facility policies.
A survey revealed multiple infection control deficiencies in an LTC facility, including improper hand hygiene, incorrect use of isolation masks, inadequate equipment sanitization, and failure to follow enhanced barrier precautions. Dietary staff served food with open wounds, and environmental cleanliness was lacking in a resident's room. The facility lacked specific infection control policies and training documentation.
The facility failed to provide written transfer notices to three residents or their representatives when they were transferred to the hospital. One resident was transferred twice for acute changes in condition, another for tingling and involuntary movements, and a third after a choking incident. Staff were unfamiliar with the requirement for written notifications, and no documentation was provided despite requests.
The facility failed to provide required bed hold notices to residents or their representatives before or after hospital transfers. Three residents were affected, with no documentation of notification in their medical records. Staff interviews revealed a lack of understanding and adherence to the facility's policy, which mandates informing residents of the bed hold policy upon admission and prior to transfer.
The facility employed an unqualified activity professional, affecting all residents participating in activities. A staff member hired in September 2024 had not completed or enrolled in an activities professional training program, and her resume confirmed she did not meet the minimum qualifications.
The facility failed to document and manage pressure ulcers for three residents, leading to deficiencies in care. A resident reported pain and had an undocumented coccyx wound, with staff unaware of its duration. Another resident's records showed discrepancies between skin assessments and wound observations, while a third resident had missed wound care sessions and incomplete assessments. The facility's wound care documentation policy was not followed.
Two residents with PEG tubes experienced deficiencies in care due to staff failing to follow physician orders and infection control protocols. One resident received excess fluid during medication administration, while another faced delayed medications affecting meal times and appetite. Staff did not adhere to enhanced barrier precautions or accurately measure fluid volumes, contributing to the deficiencies.
The facility failed to properly label, store, and dispose of medications, with observations of undated medication containers and unattended medication carts. Additionally, the facility did not monitor or document medication refrigerator and freezer temperatures as required by policy, posing risks to medication safety and security.
The facility failed to address maintenance issues in resident rooms and the Rosebud unit, affecting safety and comfort. Two residents reported long-standing issues with broken curtains and windowsills. The maintenance process was inadequate, with poor documentation and overwhelmed staff. The Rosebud medication room had a clogged sink with biofilm and mold, and a missing ceiling tile with exposed cords, with unclear cleaning responsibilities.
The facility failed to ensure the Infection Preventionist had the necessary certification for overseeing the infection control program. A staff member, who began working in February 2024, claimed to have completed the certification in 2019 but could not provide it due to a tornado in another state. The facility documented the need for the certification, but no supporting information was provided to the survey team.
A facility failed to administer pneumococcal and COVID-19 vaccines to a resident, despite having obtained consent for both. A staff member stated that all immunizations were documented in the EHR, but a review showed no record of the vaccines being given. Consent forms confirmed the resident's agreement to receive the vaccines, yet there was no evidence of administration in the EHR.
A facility failed to provide a clean and safe environment for a resident, as surveyors observed persistent unsanitary conditions in the resident's room, including a dried, crusty brown substance near an electrical outlet, stained bedding, and a sticky floor. Staff interviews revealed a lack of awareness and action regarding these issues, and the facility did not provide a housekeeping duty sheet for the resident's room. The resident's care plan emphasized the need for a safe environment due to high fall risk and bowel incontinence, yet these conditions were not met.
A facility failed to complete a comprehensive assessment of a resident's needs within 14 days of admission. The resident, observed with wounds and difficulty eating, did not have these conditions documented in their medical record. The comprehensive admission MDS assessment was 76 days overdue, despite staff acknowledging the requirement for timely submission.
A facility failed to accurately complete the Admission MDS assessment for a resident's oral status. The resident, who had no natural teeth and no dentures since admission, was incorrectly documented as having no broken or missing teeth. Staff interviews confirmed the resident's dental status and ongoing denture fitting appointments, highlighting the need for accurate MDS updates.
A facility failed to implement a comprehensive care plan for a resident with no natural teeth and no dentures, affecting her speech and eating. The resident also had hearing difficulties, wearing one hearing aid and relying on lip-reading. The care plan did not address these issues, and staff were unaware of the status of her dental appointments. Documentation gaps were noted, as dental provider notes were not available by the end of the survey.
A facility failed to update a resident's care plan to include a diagnosis of bipolar depression. Despite a physician's order to schedule a psychiatric appointment and a history and physical confirming the diagnosis, the care plan lacked focus, goals, or interventions for the condition. A PASARR Level II request was submitted, but no documentation showed it was performed. A staff member confirmed that care plans should reflect all current diagnoses.
A facility failed to conduct a trauma-informed assessment for a resident with PTSD, despite her history of abuse and regular nightmares. The resident reported that no discussions about her PTSD had occurred since admission. A staff member deemed the assessment unnecessary, as the PTSD was not an active diagnosis, although it was noted in the PASARR Level II evaluation. Documentation of the assessment was not provided during the survey.
The facility failed to ensure the DON did not work as a charge nurse when the census exceeded 60 residents. The DON was scheduled as a charge nurse on multiple occasions with a census of 69 and 76 residents. The facility's assessment indicated an average daily census of 74.5. The DON acknowledged working more on the floor recently, with plans to hire additional nurses.
A resident reported a cracked wisdom tooth and informed staff, but no dental appointment was scheduled. Staff were aware of the need for a dental cleaning but not the specific issue. Communication was verbal, with no documentation or tracking system in place. The last note on specialty appointments was months old.
The dietary department at the facility was found to be understaffed, leading to meals being served cold and late. Residents experienced delays in meal service, with breakfast often starting significantly later than scheduled. A staff member noted that the facility was short-staffed, and issues persisted despite hiring efforts. Additionally, meals were served at inadequate temperatures, and there was an instance where a cook's absence led to management purchasing alternative meals for residents.
The facility failed to ensure the safe storage of chemicals in an unlocked closet on the Rosebud unit hallway, increasing the risk of resident misuse. A surveyor found the housekeeping closet door unlocked, allowing access to chemical containers with warnings. Staff confirmed the closets should be locked, but the door was not shutting completely, preventing the lock from engaging.
Two residents experienced neglect in the facility, leading to physical and psychosocial harm. One resident was left in soiled conditions and a wheelchair for extended periods, while another had unanswered call lights and was left in a hospital gown for days. The facility failed to report these incidents to the State Survey Agency, contrary to its abuse policy.
The facility failed to address resident grievances and neglect, with multiple residents reporting issues such as unanswered call lights, neglect in personal care, and disrespectful treatment by staff. Staff interviews revealed a lack of understanding and action regarding neglect and abuse allegations, and the facility's grievance logs did not reflect the numerous complaints documented in resident council minutes. The facility lacked a proper system for anonymous grievance filing, and grievances were often not documented or investigated.
The facility failed to protect residents who reported concerns of alleged abuse or neglect and did not report neglect allegations to the State Survey Agency within the required timeframe. Incidents included a resident-to-resident altercation, a resident left in a soiled brief, and a resident not treated with dignity. The facility's policy mandates immediate reporting of such incidents, but these protocols were not followed, leading to the deficiencies noted.
A facility failed to issue a timely refund to a resident's representative, violating its policy of providing refunds within 30 days of discharge. The resident was discharged, but the refund check was delayed and not sent until over a month later, contrary to the facility's Standard Admissions Agreement.
A resident was allowed outside independently without proper assessment, leading to an incident where they were found driving a scooter on a road at night. Staff were unsure of the resident's safety for independent outdoor privileges, and the care plan lacked necessary assessments. The facility's policy was not followed, resulting in the resident leaving against medical advice.
The facility failed to ensure that residents with limited range of motion or mobility received necessary restorative services consistently. Staff were unaware of which residents required these services and lacked a backup plan when the Restorative Aide was unavailable, leading to inconsistent care for four residents.
The facility failed to provide consistent restorative nursing services due to insufficient staffing. The Restorative Aide was often reassigned to work the floor, and there was no backup plan in place. This resulted in significant gaps in the provision of restorative services for four residents, with some receiving services only a few times each month instead of the required three to five times per week.
A staff member failed to provide necessary care for a dependent resident, causing distress and discomfort. The resident, who required substantial assistance with ADLs and was cognitively intact, reported that the staff member refused to help him get out of bed and retrieve his call light, and stretched his urinary catheter tubing. The staff member resigned after the incident was investigated.
The facility did not consistently post daily staffing information as required, with 45 out of 90 days missing postings and inaccuracies in the census updates. A staff member admitted the task was not being performed regularly.
Incomplete Incident Investigations and Lack of Incident-Specific Interventions
Penalty
Summary
The deficiency involves the facility’s failure to conduct comprehensive investigations and implement appropriate, incident-specific interventions following two separate facility-reported events. In the first event, a resident with moderate cognitive impairment (BIMS score of 11) exited the building in a wheelchair through an alarmed entrance door that had been opened by a non-employee vendor, which prevented the door alarm from triggering. Staff were unaware the resident had left the building and only became aware when a family member reported the resident was outside; video surveillance later showed the resident was outside unsupervised for an estimated 15 minutes. The facility’s investigation and documentation identified the resident’s impaired memory, confusion, and desire to smoke as risk factors and focused on staff response to door alarms, but did not accurately identify or address the root cause that the resident was assisted out by a vendor and that no alarm had sounded. In the second event, a resident was found in bed with urine-soaked clothing and a soiled brief by oncoming staff after shift change, following care responsibility by a night-shift CNA. The incident was reported up the chain of command, but the facility was unable to produce documentation showing that the resident’s responsible party or provider had been notified, nor could it provide risk management or event forms with detailed information about the incident. The facility’s written findings referenced interviews with other residents on the hallway, review of security camera footage, the CNA’s resignation, and an interdisciplinary team conclusion that there had been a lapse in care and that the incident was isolated. However, there was no complete and thorough documentation of the investigation, interdisciplinary team notes, event review, staff education, or evidence of required notifications, despite facility policy requiring comprehensive written procedures and documentation for investigations and reporting of alleged abuse, neglect, and exploitation.
Failure to Revise Care Plan After Resident Elopement
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s care plan to reflect current care needs following an elopement. A facility-reported incident submitted to the State Survey Agency documented that resident #67 eloped from the facility without staff knowledge, exiting through an alarmed door that had been deactivated by a facility vendor. Staff interviews indicated that care plans were expected to be updated by nurses or designated staff after such events and on an as-needed basis. The facility’s incident investigation stated that the resident’s care plan was updated to reflect a need for closer monitoring and supervision when approaching facility exits. However, review of resident #67’s care plan entry dated 9/27/25 showed only that the resident was added to an elopement binder, educated not to leave the facility without assistance, and instructed to use an enclosed patio to enjoy the outdoors, along with general interventions such as engaging the resident in purposeful activity, identifying triggers for wandering or eloping, and providing calm, reassuring care. The care plan did not specify the need for closer supervision and monitoring when the resident approached facility exits, as identified in the incident investigation. This omission occurred despite a facility policy on elopements and wandering residents that required interventions to increase staff awareness of a resident’s risk and to minimize associated hazards to be added to the resident’s care plan and communicated to appropriate staff.
Failure to Provide Timely Incontinence and ADL Assistance
Penalty
Summary
Staff failed to respond timely to a resident’s need for assistance with activities of daily living, specifically incontinence care. A facility-reported incident documented that on 6/5/25 at 8:40 a.m., a staff member found resident #99 lying in bed in urine-soaked clothing and a soiled brief. This was discovered by day shift staff members O and L after they completed shift change report with NF3, the night shift staff member responsible for the resident’s care. During interview, staff member L stated that NF3 did not report that the resident needed his brief and clothes changed and that it was not normal routine to leave a resident in a soiled brief or clothing. Resident #99’s MDS, with a quarterly assessment reference date of 5/14/25, showed he required partial/moderate assistance for lower body dressing and toileting hygiene and was frequently incontinent of bladder and bowel. His comprehensive care plan, initiated 3/24/25 for an ADL self-care performance deficit, included an intervention for staff to check him regularly for incontinence episodes and provide prompt peri-care after such episodes. The facility’s interdisciplinary team investigation identified a lapse in care by NF3 related to this incident, during which the resident remained in soiled clothing and a soiled brief without timely incontinence care.
Failure to Ensure Dietary Staff Wore Required Hair and Beard Coverings During Food Preparation
Penalty
Summary
Dietary staff failed to follow safe and sanitary food handling practices by not consistently wearing required hair coverings and beard nets while preparing and serving meals in the facility kitchen. Observations showed a staff member working at the kitchen grill and serving area without a hair covering or beard net, and again dishing food onto plates for resident meals without the appropriate protective attire. The staff member admitted to frequently forgetting to wear the required coverings, citing being new to the cook position and getting busy as reasons for non-compliance. Interviews with another staff member confirmed that all dietary staff are expected to wear hair coverings and beard nets if they have facial hair, and that the staff member in question had been informed of this requirement. The facility's policy on work clothing and attire also mandates a neat, professional appearance and proper attire for employees providing patient care. Despite these expectations and ongoing audits, the deficiency persisted, resulting in a failure to maintain sanitary conditions in food preparation areas.
Failure to Ensure Safe Self-Administration and Secure Storage of Medications
Penalty
Summary
The facility failed to ensure an interdisciplinary team was involved in determining whether a resident was safe to self-administer medication and did not implement a system to secure as-needed medication in the resident's room. A resident with limited mobility and minimal movement in her hands and arms was left with a sample of Blu Emu cream in a medication cup on her bedside table, without a locked container for secure storage. The resident did not use the cream, and it remained on her bedside table. On one occasion, a staff member left a white cream, ordered by the medical provider for underarm application, on the resident's bedside table. Later, another staff member mistakenly applied the Blu Emu cream instead of the prescribed white cream to the resident's underarm, resulting in a temporary burning sensation. The resident's medical record showed that the medication self-administration assessment was not reviewed by the facility's interdisciplinary team, and the facility's policy requiring assessment of the resident's ability to self-administer and secure storage of medications was not followed.
Failure to Safely Administer Topical Medication
Penalty
Summary
Facility nursing staff failed to meet professional standards of practice by not ensuring the safe administration of a scheduled topical medication for one resident. A nurse received an order for Triamcinolone Acetonide cream to be applied under the resident's right and left underarms for skin irritation. Instead of applying the cream as ordered, the nurse placed the medication in a clear 30cc medication cup and left it unsupervised on the resident's bedside table, intending to return later to apply it. The nurse was new to the facility and stated she had previously worked in states where certified nursing assistants (CNAs) were permitted to apply topical creams, but could not explain why she left the medication at the bedside. Later that evening, a CNA assisted the resident in preparing for bed and, at the resident's request, applied a cream from a cup found on the bedside table. The resident experienced a burning sensation under her right arm after the application, prompting the CNA to attempt relief with a cold cloth and then to wash the area with soap and water, which alleviated the discomfort. The resident clarified that the cream applied was blue and had been left at her bedside by a nurse days earlier for muscle soreness, while the prescribed white cream remained unused. The medication administration record indicated the Triamcinolone Acetonide cream was documented as administered, but the nurse failed to ensure it was safely and correctly applied.
Failure to Follow Two-Person Transfer Protocol with Hoyer Lift
Penalty
Summary
A staff member failed to follow established facility protocols for the safe transfer of a resident using a Hoyer lift. Specifically, the staff member transferred a resident from a wheelchair to bed at night without the required assistance of a second staff member. This action was reported by the resident through a grievance, and the staff member later confirmed during an interview that he performed the transfer alone because he could not find another staff member to assist. Facility records and staff interviews confirmed that all staff are educated and trained on the requirement that two staff members must be present for all resident transfers involving mechanical lifts, including Hoyer and sit-to-stand lifts. Documentation showed the staff member involved had completed competency training on the use of these lifts and had received in-service education on proper transfer protocols. Despite this, the protocol was not followed during the incident involving the resident.
Unlabeled Topical Medications Lead to Incorrect Application and Resident Discomfort
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure the safe administration of a scheduled topical medication for one resident. A staff member, while assisting the resident to bed, applied a blue cream from an unlabeled medication cup left at the bedside, instead of the prescribed white cream. The blue cream had been previously left at the bedside by a nurse for muscle soreness, per a provider order allowing it to be kept at bedside. After application, the resident experienced a burning sensation under her right arm, which was only relieved after the staff member washed off the cream and applied the correct white cream as requested by the resident. The nurse had placed two unlabeled medication cups, one with white cream (Triamcinolone Acetonide) and one with blue cream (Blue-Emu), on the resident's bedside table without providing instructions or labeling. The staff member who applied the cream was not given guidance on which cream to use. Facility policy requires that only licensed or permitted individuals prepare, administer, and document medications, and that the right medication, resident, dosage, time, and route be verified before administration. These steps were not followed, resulting in the resident receiving the wrong topical medication and experiencing temporary discomfort.
Failure to Use Enhanced Barrier Precautions During Resident Transfer
Penalty
Summary
Staff failed to follow enhanced barrier precaution protocols during a high-contact care activity involving a resident with an indwelling urinary catheter. During a transfer from bed to wheelchair using a sit-to-stand lift, two staff members wore gloves but did not don gowns, despite their uniforms coming into direct contact with the resident's upper and lower body. The resident confirmed that staff typically wear gowns and gloves during catheter care but not during transfers. The facility's infection preventionist stated that all nursing staff are educated on the requirement to wear gowns and gloves for residents on enhanced barrier precautions during high-contact activities, including transfers. Facility policy, revised in April 2024, specifies that staff should wear gloves and gowns during such activities for residents at increased risk of carrying resistant organisms, such as those with indwelling medical devices. One staff member acknowledged not wearing a gown during the transfer, citing a busy environment.
Food Storage and Cleanliness Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food storage and cleanliness, as observed in multiple instances. In the walk-in cooler, several food items, including cheese slices, Cool Whip, and a tub of red liquid, were found without labels or dates. The cooler's floors and shelves were also dirty, with splatter marks and debris. Staff member S admitted that leftover fruit should have been discarded and that the rice, which was actually chicken soup, was not properly labeled. The facility's policy requires all items to be labeled and dated, with a discard date set seven days from opening. In the nutrition room refrigerator on the Yellowstone Hall, a personal lunch box was found, along with open containers of chip dip and a carafe of yellow liquid, all without labels or dates. Moldy noodles and vegetables were observed in the sink drain. Staff member S acknowledged that the soup in the nutrition room was the same as the rice in the walk-in cooler and should not have been there. The facility's policy mandates that all foods in the refrigerator or freezer be covered, labeled, and dated, and that partially eaten food should not be kept. The Rosebud unit's resident food refrigerator was found with several unlabeled and expired items, including a cold brew coffee can, a bottle of diet Pepsi, and a bottle of Brisk iced sweet tea. The refrigerator's thermometer was improperly placed and stuck in a sticky substance. Staff members Q, O, and C provided conflicting information about who was responsible for checking and cleaning the refrigerator. The facility's policy requires that refrigerator temperatures be monitored and recorded, and that food items be labeled with a 'use by' date. The Rosebud Refrigerator Temperature Log showed temperatures outside the acceptable range and missing entries, indicating a lack of proper monitoring and maintenance.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to proper infection control practices, as observed during a survey. Staff members were noted to neglect hand hygiene protocols, such as changing gloves and using hand sanitizer after handling soiled items and before touching clean items or residents. This was evident in multiple instances, including when staff members changed a resident's brief and prepared medications without proper hand hygiene. Additionally, some staff members were observed handling medications with ungloved hands and moving in and out of resident rooms without doffing gloves or performing hand hygiene. One staff member admitted to not receiving any hand hygiene education at the facility. The use of isolation masks was also improperly managed. Staff members were seen touching their masks and not wearing them correctly, even during a COVID-19 outbreak. Equipment sanitization was another area of concern, with staff failing to disinfect items like medication cart cords and glucometers after use. Enhanced barrier precautions were not followed during enteral medication administration, with staff only wearing gloves instead of the required protective equipment. Dietary infection control was compromised as well, with staff serving food while having open wounds that were not properly covered. The facility lacked a specific infection control policy for the dietary department, and there was no evidence of infection control training for some staff members. Environmental cleanliness was also an issue, with persistent unclean conditions in a resident's room, including dried substances on the wall and floor. Housekeeping staff were expected to clean daily, but there was no documentation to verify this was done consistently.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to provide written notice of the reason for a facility-initiated transfer to three residents or their representatives. Resident #18 was transported to the hospital on two occasions for acute changes in condition, but the medical record did not show any written notice of the transfer was provided. During an interview, a staff member admitted to being unfamiliar with the federal regulation and facility policy regarding written notifications for transfers. Despite requests for documentation, no transfer notifications were provided for these hospital transfers. Similarly, resident #64 was transferred to the hospital for tingling and involuntary movements, but there was no written notice of transfer provided. The resident confirmed not receiving any paperwork. Additionally, resident #78 was hospitalized after a choking incident and did not return to the facility, yet no documentation of the transfer notice was provided. A staff member acknowledged the lack of completed transfer notices as a trend that needed addressing. The facility's policy requires a discharge/transfer form and other documents to be reviewed with the resident or representative, but this was not adhered to in these cases.
Failure to Provide Bed Hold Notices
Penalty
Summary
The facility failed to provide the required bed hold notice to residents or their representatives prior to or shortly after a transfer to a hospital or therapeutic leave. This deficiency was identified for three residents out of a sample of 36. Resident #18 was transported to the hospital on two occasions, and there was no documentation in the medical record indicating that the resident or their representative was notified of the bed hold policy. During an interview, a staff member admitted to not knowing who was responsible for the bed hold documentation or how the process worked. Despite requests for documentation, no bed hold notifications were provided for resident #18's hospital transfers. Similarly, resident #64 was transferred to the hospital, and the medical record did not show that the resident or their representative was notified of the bed hold policy. The resident confirmed in an interview that they did not sign or receive any paperwork. Resident #78 was hospitalized after a choking incident and did not return to the facility. The facility failed to provide documentation of the bed hold policy notification for this resident as well. A staff member acknowledged that the notifications were not being completed and recognized it as a trend that needed to be addressed. The facility's policy requires that residents be informed of the bed hold policy upon admission and prior to transfer, but this was not adhered to in these cases.
Unqualified Activity Professional Employed
Penalty
Summary
The facility failed to employ a qualified activity professional to direct the activity program, which may affect all residents participating in activities. During an interview, a staff member stated she was hired in September 2024, but had not completed and was not currently enrolled in an activities professional training program. A review of her resume confirmed that she did not meet the minimum qualifications required to direct the activity program.
Inadequate Documentation and Management of Pressure Ulcers
Penalty
Summary
The facility failed to accurately document and manage pressure ulcers for three residents, leading to deficiencies in care. Resident #57 reported pain and had a coccyx wound that was not documented in her electronic health record (EHR) until after a surveyor inquiry. Staff members were unaware of the wound's duration, and there was a lack of wound assessments in the EHR. An interview revealed that the resident had been in painful positions and her brief was not changed frequently, contributing to the development of the wound. Additionally, there was inconsistency in weekly skin assessments and wound documentation, indicating a need for staff education. Resident #11's records showed discrepancies between weekly skin assessments and wound observations, with a Stage 4 pressure ulcer documented but not reflected in the skin assessment. Similarly, Resident #76 had a Stage 4 pressure ulcer that was not consistently documented, with missed wound care sessions and incomplete weekly skin assessments. The facility's wound care documentation policy was not followed, as evidenced by the lack of recorded wound care details in the residents' medical records.
Deficiencies in PEG Tube Management and Infection Control
Penalty
Summary
The facility failed to adhere to physician orders and proper procedures for residents with PEG tubes, leading to deficiencies in care. For resident #3, a staff member administered medications through a PEG tube without accurately measuring and recording the total fluid volume, exceeding the physician's order of a maximum of 150 mL by administering at least 185 mL. Additionally, the staff member did not check the placement of the PEG tube after it moved, which was a recurring issue, and continued to administer medications despite feeling resistance, attributing it to the syringe tip. Resident #20 experienced delays in medication administration, which affected his meal schedule and appetite. His medications, scheduled for early morning, were often given late, leading to a mismatch between meal and medication times. This resident also experienced significant weight loss over a few months. During medication administration, staff failed to follow enhanced barrier precautions, did not check PEG tube placement, and did not flush the tube as per physician orders. Medications were not properly dissolved, and the total fluid volume was not measured or recorded. The facility's staff demonstrated a lack of adherence to infection control protocols and physician orders, particularly concerning hand hygiene and enhanced barrier precautions. Staff members were observed not removing gloves or sanitizing hands between tasks, and medications were administered without proper flushing or checking of PEG tube placement. These actions contributed to the deficiencies noted in the care of residents with PEG tubes.
Medication Management and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications, as well as the disposal of expired medications. During an observation, a medication cart was found with scattered loose pills and several opened and undated medication containers, including stool softener, Vitamin B Complex, Zinc, Folic Acid, Senna, Aspirin, Milk of Magnesia, and Mylanta. Staff confirmed that opened medication bottles should be dated and replaced within 30 days, but this was not adhered to. Additionally, a nasal spray had an opened date written over its expiration date, obscuring the information. Furthermore, a medication cart was left unattended with medication cards on top, and a Handihaler Device was found on the floor, indicating lapses in medication security and handling. The facility also failed to monitor and document medication refrigerator and freezer temperatures. Observations revealed that the Rosebud unit medication room refrigerator lacked temperature logs, and a request for temperature logs from July to October 2024 was not fulfilled. The facility's policy requires daily temperature checks and documentation, but this was not followed. Additionally, a medication cart was observed unlocked and unattended in a hallway, with the nearest nurse out of view, posing a risk of unauthorized access to medications. These deficiencies highlight significant lapses in medication management and storage protocols within the facility.
Maintenance and Sanitation Deficiencies in Resident Rooms and Medication Room
Penalty
Summary
The facility failed to address maintenance issues in residents' rooms and the Rosebud nursing unit area, compromising the safety, functionality, and comfort of the environment. Two residents reported long-standing maintenance issues in their rooms. One resident had broken curtains that had been non-functional for over a year, preventing them from adjusting the light in their room. Another resident reported a broken windowsill that had been in disrepair since they moved into the facility over two years ago. Despite informing staff members about these issues, the problems remained unresolved. The maintenance process at the facility was found to be inadequate. Staff member G, responsible for maintenance, acknowledged the lack of proper documentation and communication regarding maintenance requests. The maintenance book contained only three requests, none of which addressed the issues reported by the residents. Staff member G admitted to being overwhelmed with responsibilities, including maintenance for both the nursing home and an assisted living facility nearby, and noted difficulties in retaining additional maintenance staff. The Rosebud unit's medication room was observed to be in a state of disrepair and unsanitary conditions. The sink in the medication room was clogged, with standing water and various substances, including biofilm and mold, present. The room also had a missing ceiling tile with exposed cords and a water-stained ceiling tile. Staff interviews revealed that the sink had been non-functional for a significant period, and there was confusion about cleaning responsibilities. Despite the sink's condition, there was no signage indicating it should not be used, and maintenance records for the sink were not provided during the survey.
Infection Preventionist Certification Deficiency
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist had the necessary certification to oversee the infection control program. During an observation, a staff member stated that she began working at the facility in February 2024 and had completed the infection preventionist certification in 2019. However, she was unable to provide the certification due to a tornado in another state that resulted in the loss of the document. The facility's request sheet, dated November 7, 2024, documented the need for the Infection Preventionist Certification, but no certification or supporting information was provided to the survey team before the survey concluded.
Failure to Administer Vaccines Despite Consent
Penalty
Summary
The facility failed to provide pneumococcal and COVID-19 vaccines to a resident, despite having obtained consent for both vaccinations. During an interview, a staff member indicated that all immunizations were documented in the Electronic Health Record (EHR), and no additional documentation existed outside of the EHR. However, a review of the resident's EHR showed no record of the vaccines being administered. Consent forms dated 9/24/24 confirmed that the resident had agreed to receive both the pneumococcal and COVID-19 vaccines, yet there was no evidence in the EHR that these vaccines were given. The resident's immunization records were requested the following day.
Failure to Maintain a Clean and Safe Environment for a Resident
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for a resident, as evidenced by multiple observations of unsanitary conditions in the resident's room. On several occasions, surveyors noted a dried, crusty brown substance near an electrical outlet next to the resident's bed, which persisted over multiple days. Additionally, a large amount of white, dried crusted substance was observed on the resident's bedding, and the privacy curtain next to the resident's recliner had dark brown, dried stains. The floor alongside the resident's bed was sticky with debris, and new stains appeared over time, indicating a lack of thorough cleaning. Interviews with staff revealed a lack of awareness and action regarding the cleanliness issues. A staff member speculated that the brown substance might be chocolate pudding, while another thought it resembled feces stains. The staff member responsible for changing the resident's bed sheets did not notice the stains, and it was noted that curtains in resident rooms were not regularly changed or replaced. Despite the facility's housekeeping protocol, which included cleaning resident rooms and floors, the requested housekeeping duty sheet for the resident's room was not provided during the survey. The resident's care plan highlighted the need for a safe environment due to high fall risk and bowel incontinence, yet the observed conditions contradicted these requirements.
Failure to Complete Timely Comprehensive Assessment
Penalty
Summary
The facility failed to complete a comprehensive assessment of a resident's needs, strengths, goals, life history, and preferences within 14 days of admission for one of the sampled residents. During an observation and interview, the resident was noted to have wounds on both legs and the left arm, and was having difficulty eating, with their left hand resting in the food on their plate. Despite these observations, the facility's documentation did not indicate any medical conditions, including wounds, for the resident. The resident's medical record showed that the comprehensive admission MDS assessment was due 14 days after admission but remained incomplete and unsubmitted 76 days past the due date, as of the last day of the survey period. A staff member confirmed that initial admission MDS assessments are supposed to be conducted and submitted within the required timeframe, but this was not done for the resident in question.
Inaccurate MDS Assessment of Resident's Oral Status
Penalty
Summary
The facility failed to accurately complete the Admission Minimum Data Set (MDS) assessment for a resident's oral status. During an observation and interview, it was noted that the resident had no natural teeth and no dentures, which the resident confirmed had been the case since her admission. The resident had her teeth removed prior to admission and had not yet been fitted with dentures. Despite this, the Admission MDS assessment inaccurately indicated that the resident had no broken or missing teeth. Interviews with staff confirmed that the resident had no teeth upon admission and had attended several appointments for denture fittings. The staff member responsible for MDS assessments acknowledged the need to update and ensure the accuracy of the resident's MDS information.
Failure to Implement Comprehensive Care Plan for Resident with Dental and Hearing Needs
Penalty
Summary
The facility failed to implement a comprehensive, resident-centered care plan for a resident who had no natural teeth and no dentures, which affected her ability to speak clearly and eat comfortably. The resident expressed embarrassment and difficulty in communication due to the absence of teeth and was awaiting dentures, which were delayed due to jaw problems. Despite being on a bite-sized diet, the resident still faced challenges in eating. Additionally, the resident had hearing difficulties, wearing one hearing aid and relying on lip-reading for communication. During the survey, it was found that the resident's care plan, initiated in September, did not address her dental, eating, dietary modifications, or hearing difficulties. Staff interviews revealed a lack of awareness and documentation regarding the resident's dental appointments and the status of her dentures. The facility was unable to provide dental provider notes by the end of the survey, indicating a gap in the documentation and follow-up on the resident's care needs.
Failure to Revise Care Plan for Mental Health Diagnosis
Penalty
Summary
The facility failed to revise an individualized comprehensive care plan to include a mental health diagnosis for a resident with bipolar depression. The resident's physician's order, dated 10/3/24, indicated the need to schedule an appointment with Encounter Telehealth Psychiatry for bipolar disorder and depression. However, the care plan initiated on 9/3/24 did not include any focus, goals, or interventions related to the diagnosis of bipolar depression. The most recent history and physical, dated 1/30/24, confirmed bipolar depression as an active diagnosis. Additionally, the facility had submitted a letter requesting a PASARR Level II for the resident on 9/13/24 due to the history of bipolar depression, but there was no documentation provided by the end of the survey period to show that a PASARR Level II was performed. During an interview, a staff member stated that care plans should be completed upon admission, quarterly, or with any change in a resident's condition and should reflect all current diagnoses.
Failure to Conduct Trauma-Informed Assessment for Resident with PTSD
Penalty
Summary
The facility failed to conduct a trauma-informed assessment for a resident diagnosed with post-traumatic stress disorder (PTSD). The resident, who had a history of abuse, reported experiencing regular nightmares and stated that no one from the facility had discussed her PTSD since her admission. Despite the resident's PTSD diagnosis being noted in her PASARR Level II evaluation, a staff member believed a trauma-informed assessment was unnecessary because the PTSD was not considered an active diagnosis. A psychiatric telehealth note indicated that the resident was seen for an initial consultation for PTSD treatment. However, the facility did not provide documentation of a trauma-informed assessment before the survey concluded.
DON Worked as Charge Nurse Despite High Census
Penalty
Summary
The facility failed to ensure that the Director of Nursing (DON) did not work as a charge nurse when the average daily census exceeded 60 residents. This deficiency was identified through a review of nursing schedules and census records, which showed that the DON, referred to as staff member B, was scheduled to work as a charge nurse on multiple occasions when the census was 69 and 76 residents. Specifically, staff member B worked as a charge nurse on the day shift from 6-12 on 4/27/24, from 3-6 on 4/28/24, and on the night shift from 10-6 on 10/4/24. The facility's assessment tool indicated an average daily census of 74.5 residents. During an interview, staff member B acknowledged working on the floor more frequently in the past week and a half, but mentioned that the facility planned to hire two more nurses to alleviate this issue.
Failure to Provide Dental Services for a Resident
Penalty
Summary
The facility failed to provide necessary dental services for one resident, who reported a cracked wisdom tooth. The resident expressed that she had informed multiple staff members about her dental concerns but was not aware of any scheduled appointment. Staff member E acknowledged awareness of the resident's need for a dental cleaning but was unaware of the specific issue with the wisdom tooth. Communication regarding the appointment was reportedly verbal, and no documentation or tracking system was in place to ensure the appointment was scheduled or completed. Staff member E admitted to not documenting meetings with residents regularly and was behind on quarterly meetings. Additionally, staff member E did not specifically inquire about the need for dental appointments during interactions with residents. The last documented note regarding specialty appointments for the resident was dated several months prior.
Dietary Department Staffing Deficiency
Penalty
Summary
The dietary department at the facility failed to provide sufficient staffing to safely and effectively carry out the functions of the food and nutrition services. This deficiency was observed through multiple instances of meals being served cold and late to residents. On several occasions, residents were observed waiting for breakfast well past the scheduled meal time, with breakfast service starting significantly later than planned. Staff member S, who was responsible for serving meals, expressed concerns about being short-staffed and mentioned that the facility had recently hired one dietary staff member, but issues persisted due to staff absences and resignations. Further observations revealed that meals were not only served late but also at inappropriate temperatures. For instance, a staff member checked the temperature of sausage on a tray and found it to be 106 degrees Fahrenheit, which was acknowledged as inadequate. Additionally, there was an incident where a cook did not show up, leading to management purchasing pancake platters for residents as a substitute meal. Staff member S highlighted the ongoing challenge of managing meal services with insufficient personnel, resulting in meals being consistently delayed by 30 minutes or more for over a month.
Unsafe Storage of Chemicals in Unlocked Closet
Penalty
Summary
The facility failed to ensure the safe storage of chemicals in an unlocked closet on the Rosebud unit hallway, which increased the risk of resident misuse of the chemicals. During an observation, a surveyor found that a housekeeping closet door was closed but unlocked, allowing access without a code or key. Inside the closet, there were three chemical containers with Ecolab labels, each displaying warnings and first aid precautions. Staff member V confirmed that the housekeeping and janitor supply closets were supposed to be locked when not in use, but the door could be opened without a code or key. Further observations and interviews revealed that the door to the Rosebud unit hallway housekeeping closet was not shutting completely, preventing the lock from engaging properly. Staff member U also confirmed that the doors to these closets, which contain cleaning supplies and chemicals, should be locked and closed when not in use. Despite requests for documentation or policies on securing housekeeping or maintenance rooms, no such documentation was provided by the end of the survey.
Neglect of Residents Leading to Harm
Penalty
Summary
The facility failed to protect two residents from neglect, resulting in physical and psychosocial harm. Resident #15 experienced neglect when a staff member refused to change his brief, leaving him in soiled conditions for an extended period. This neglect led to skin breakdown and pain. The resident was also left in a wheelchair for six hours, causing back pain and concern about pressure sores. Despite complaints from a family member, the staff member continued to work with residents, and the incident was not reported to the State Survey Agency. Resident #1 was not treated with dignity and respect, as evidenced by unanswered call lights and being left in a hospital gown for five days. The resident's call light was on for extended periods on multiple occasions, leading to distress and a request for immediate discharge. The facility did not respond to the grievance filed by the resident's family, and the neglect was not reported to the State Survey Agency. The facility's abuse policy requires immediate reporting of neglect, but the administrator failed to report these incidents. The administrator was unaware of the requirement to report neglect, believing only abuse and misappropriation of funds needed reporting. This lack of reporting and failure to follow protocol contributed to the ongoing neglect of residents.
Failure to Address Resident Grievances and Neglect
Penalty
Summary
The facility failed to promptly resolve grievances brought forth by residents, provide a means for anonymous grievance filing, and ensure thorough investigations into grievances. Multiple residents reported issues such as unanswered call lights, neglect in personal care, and disrespectful treatment by staff. For instance, one resident was left in a hospital gown for five days and did not receive a timely refund, while another resident's call lights were not answered for extended periods, leading to distress and discomfort. Staff interviews revealed a lack of understanding and action regarding neglect and abuse allegations. The administrator admitted to not knowing the requirement to report neglect and failed to document or investigate complaints. Residents expressed frustration over the lack of response to their grievances, with some being told to stop complaining or to consider moving out if they were dissatisfied. The facility's grievance logs did not reflect the numerous complaints documented in resident council minutes, indicating a systemic issue in grievance handling. The facility's policies on filing grievances and abuse were not adhered to, as evidenced by the absence of investigations and corrective actions for reported grievances. Staff members reported grievances to management, but no changes were observed, leading to a perception of management ignoring the issues. The facility lacked a proper system for anonymous grievance filing, and grievances were often not documented or investigated, leaving residents unprotected and their concerns unaddressed.
Failure to Timely Report Alleged Abuse and Neglect
Penalty
Summary
The facility failed to protect residents who reported concerns related to alleged abuse or neglect and did not report neglect allegations to the State Survey Agency within the required 24-hour timeframe for three residents. Additionally, the facility did not report the investigative findings of reported incidents within five days for three residents. Specific incidents included a resident-to-resident altercation where findings were reported late, and a resident left in a soiled brief for an extended period, which was not reported promptly due to improper protocol by staff. Another incident involved a resident-to-resident altercation with delayed reporting of findings. Further deficiencies were noted in the handling of an injury of unknown origin and a resident-to-resident incident, both of which had delayed reporting of final findings. Additionally, a resident was not treated with dignity and respect, with call lights unanswered and left in a hospital gown for several days, which was not reported as neglect due to the administrator's misunderstanding of reporting requirements. The facility's policy mandates immediate reporting of abuse, neglect, and other violations, but these protocols were not followed, leading to the deficiencies noted.
Delayed Refund to Resident's Representative
Penalty
Summary
The facility failed to issue a refund to a resident's representative within the required 30-day period following the resident's discharge. During an interview, it was revealed that the representative did not receive the refund check until over a month after the discharge date. The resident was discharged on May 7, 2024, but the refund check was not sent until June 10, 2024, and was cashed on June 21, 2024. This action was in violation of the facility's Standard Admissions Agreement, which mandates that refunds be made within thirty days of a resident's death, transfer, or discharge.
Failure to Assess Resident for Independent Outdoor Privileges
Penalty
Summary
The facility failed to ensure that a resident was appropriately assessed for independent outdoor privileges and did not ensure the resident was inside the facility at night. This deficiency involved a resident who was given a new scooter and outside privileges without a proper assessment. A nurse expressed concerns about the resident's safety outside, but another staff member had granted the privileges. The resident was later found driving his motorized scooter down a road at night, which led to a motorist contacting the facility. Interviews with staff revealed that there was confusion and lack of communication regarding the resident's leave privileges. Staff members were unsure if the resident was safe to be outside independently, especially at night. The facility's policy required a care plan for independent leave privileges, but the resident's care plan did not include an assessment for outdoor independence or elopement risk. The facility's investigation confirmed that the leave of absence assessment was not completed before the incident, and the resident left the facility against medical advice the following day.
Failure to Provide Consistent Restorative Services
Penalty
Summary
The facility failed to ensure that residents with limited range of motion or mobility received the necessary restorative services to maintain their highest level of functioning. This deficiency was identified for four residents who were supposed to receive restorative services. Staff interviews revealed a lack of awareness and coordination regarding which residents required these services and when they were provided. Specifically, staff members were unsure how to ensure restorative services were delivered, especially when the Restorative Aide (RA) was pulled to work the floor due to staffing shortages. There was no clear backup plan or system in place to track and assign these services in the Electronic Health Record (EHR), leading to inconsistent and inadequate care for the residents in need of restorative services. Resident #1 was supposed to receive ambulation and range of motion services three to five times per week to maintain strength and mobility. However, the resident's records showed no restorative services provided in February, only two instances in March, and three in April. Similarly, Resident #3, who was a fall risk and required assistance with all activities of daily living, was supposed to receive restorative services three to five times per week. The records indicated no services in February, only one instance in March, and three in April. Resident #8, who had limited range of motion and required assistance with transferring to and from his electric wheelchair, also received inconsistent restorative services, with nine instances in February, two in March, and two in April. Resident #13, who had contractures and required restorative services to maintain his range of motion, showed similar inconsistencies. The resident received services nine times in February, twice in March, and three times in April. The facility's policy stated that residents would receive restorative nursing care as needed to promote optimal safety and independence, but the lack of a coordinated system and backup plan resulted in these residents not receiving the necessary care consistently. Staff members were unaware of any tasks in the EHR to facilitate the provision of restorative services when the RA was unavailable, leading to a failure in maintaining the residents' highest level of functioning.
Insufficient Staffing for Restorative Nursing Services
Penalty
Summary
The facility failed to ensure there was sufficient staffing available to consistently provide restorative nursing services for four residents. Interviews with staff members revealed that the Restorative Aide was frequently pulled from their duties to work the floor due to short staffing, resulting in the lack of consistent restorative services. Staff members indicated that there was no backup plan in place when the Restorative Aide was reassigned, and the switch from electronic health records (EHR) to paper charting further complicated the identification of residents needing restorative services. Review of the Restorative Care Flow Record for the affected residents showed significant gaps in the provision of restorative services. In February, two residents did not receive any restorative services, while in March and April, all four residents received services only a few times each month, far below the required frequency of three to five times per week. This deficiency had the potential to affect any resident identified as needing restorative nursing services.
Staff Member Fails to Assist Dependent Resident
Penalty
Summary
A staff member failed to provide necessary care and services for a dependent resident, causing the resident to become upset and tearful. The incident involved a resident who required substantial assistance with activities of daily living (ADLs) and was cognitively intact. The resident reported that the staff member refused to assist him in getting out of bed to a chair and also refused to retrieve his call light. Additionally, the staff member stretched the resident's urinary catheter tubing, causing discomfort. The staff member involved voluntarily resigned following the investigation of the incident.
Failure to Post Daily Staffing Information
Penalty
Summary
The facility failed to post the required daily staffing information consistently and accurately, as mandated. A review of the facility's daily staff posting information from 1/22/24 to 4/23/24 revealed that 45 out of 90 days were missing postings. Additionally, none of the 45 postings received included the name of the facility, and 11 were missing the number of hours actually worked. The facility also failed to update the census to reflect admissions accurately, with only three days showing the appropriate increase in census out of 26 days with at least one admission. During an interview, a staff member acknowledged the inconsistency in posting and admitted that the task was not being performed regularly.
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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