Sheridan Memorial Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Plentywood, Montana.
- Location
- 440 W Laurel Ave, Plentywood, Montana 59254
- CMS Provider Number
- 275070
- Inspections on file
- 21
- Latest survey
- April 9, 2026
- Citations (last 12 mo.)
- 27
Citation history
Health deficiencies cited at Sheridan Memorial Nursing Home during CMS and state inspections, most recent first.
A resident was kept in a recliner in a common lounge instead of being allowed to remain in bed, despite requesting to return to bed, and was described by staff as unusually anxious and distraught. During night shift, staff told the resident she would not receive water because she would need to get up to use the bathroom, and the resident reported being told not to use the call light, being refused an ice pack, and having no way to summon help. Day-shift staff observed the resident without water nearby and heard night-shift staff state in front of the resident that she did not get water because she would need to get up. Facility investigative notes indicated the resident’s walker was moved farther away, her request to return to bed was dismissed, and she reported feeling punished and worthless, leading the facility to determine the incident met the definition of abuse under its abuse policy.
Staff failed to use a gait belt while assisting a resident who was ambulating with a rolling walker and on supplemental O2, then turned away from the resident, resulting in a backward fall and a skin tear with tendon exposure to a finger. The same resident had multiple additional unwitnessed falls and a near miss related to ambulation and oxygen tubing. Two other residents with repeated unwitnessed falls, including one with Parkinson-related freezing and another with weakness, confusion, tremors, and sepsis onset, had numerous fall events discussed in weekly fall meetings, but their fall care plans were not updated to reflect the interventions identified. Staff interviews confirmed expectations for gait belt use and individualized gait belts, and revealed that care plans were not being revised after fall meetings despite a facility fall-prevention policy allowing addition of interventions to care plans.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents. The environment did not meet safety standards, and there was insufficient oversight in the area.
The facility did not have a grievance policy that included instructions for anonymous submissions and failed to post the grievance officer's contact information. Two residents were unaware of how to file grievances or where to find forms, and staff handled concerns verbally without documentation. The available drop box was labeled for suggestions, not grievances, and the written policy lacked guidance on anonymous submissions.
The facility did not maintain required documentation showing the Medical Director or designee's attendance at QAPI meetings, as only one instance of attendance was recorded over several months. Staff confirmed that meetings occurred and that the Medical Director or designee sometimes participated via video conferencing, but there were no sign-in sheets or consistent records to verify this, resulting in a failure to meet regulatory requirements for QAPI committee documentation.
Staff failed to perform required hand hygiene before and during medication administration for multiple residents, including handling dropped medication and touching various surfaces and resident items without sanitizing hands or equipment, contrary to facility policy and infection control standards.
A resident with chronic atrial fibrillation and on Coumadin therapy returned from the hospital with a critically elevated INR and a large hematoma. Despite hospital instructions to hold Coumadin, the medication was continued in the LTC facility due to a communication breakdown and lack of nursing follow-up, resulting in the resident receiving unnecessary doses. Staff did not question the order or notify the provider as required by facility policy.
A resident with a documented history of PTSD and significant past trauma did not have their diagnosis, triggers, or appropriate interventions identified in their care plan. Staff were aware of the resident's trauma history and triggers but lacked a process to communicate this information, and the resident's MDS assessment did not reflect the PTSD diagnosis. No trauma-informed care assessment or social history was available, resulting in a failure to provide trauma-informed and culturally competent care.
A resident with severe cognitive impairment and on a pureed diet lost his upper partial denture, and the facility did not promptly refer him to dental services or offer a replacement. The resident experienced significant weight loss, and staff interviews revealed a lack of awareness and documentation regarding the missing denture.
A facility failed to report an allegation of verbal abuse by a staff member towards a resident within the required 24-hour timeframe. The incident was reported internally on the day it occurred but was not submitted to the State Survey Agency until five days later. The staff member responsible for reporting could not explain the delay, and the facility's policy lacked specific reporting timelines.
A resident was not included in care plan meetings, despite being cognitively intact and expressing a desire to participate. The resident's electronic medical record lacked documentation of invitations to these meetings. A staff member confirmed that while family members were contacted, the resident was not invited, and no documentation of such invitations was maintained.
A facility failed to identify bilateral grab bars as a potential restraint for a resident, neglecting to complete a risk assessment, obtain consent, or implement restraint monitoring. Observations showed grab bars on the resident's bed, and interviews indicated possible consent due to the resident's fall history. However, the medical record lacked necessary documentation, and staff noted the grab bars were not used as assistive devices. The facility's policy stated restraints would not be used for convenience.
A facility failed to ensure a pharmacist monitored a resident's as needed psychotropic medication for excessive duration. The resident received lorazepam for over 14 days without the pharmacist addressing the issue with the medical provider, contrary to facility policy. A staff member was unaware of the prolonged order, highlighting a lapse in monitoring and communication.
A facility failed to limit a resident's PRN lorazepam order to 14 days without documented rationale from a provider. The resident's MAR showed lorazepam was administered twice, but the order remained active beyond the 14-day limit. A staff member was unaware of the ongoing order, and the pharmacist did not identify or address the issue during medication regimen reviews. The facility's policy required PRN psychotropic orders to be limited to 14 days and used only for specific, documented circumstances.
A resident with a history of elopement and confusion managed to leave the facility unsupervised, resulting in a fall and facial injuries. Despite staff efforts to redirect him, the resident exited the building by catching the main door before it latched. The facility's Roam Alert System was unreliable, and staff had become desensitized to its alarms. The resident's care plan included interventions for his elopement risk, but these were insufficient to prevent the incident.
Resident Kept in Recliner, Denied Water and Call Light, Resulting in Abuse Finding
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse and neglect of care needs when the resident was forced to remain in a recliner in a day lounge, denied water upon request, and left without access to a call light or other means to summon help. A facility-reported incident documented that the resident reported being kept in an uncomfortable recliner in a common area instead of in bed, being told she could not have water because she would need to get up to use the bathroom, and not being allowed to use her call light. The resident repeatedly expressed feeling as if she was being punished and reported feeling as though she was not worth anything due to the way she was treated during the night shift. Staff interviews and written statements corroborated key aspects of the resident’s account. When day-shift staff arrived, they found the resident in a recliner in the day lounge, which was unusual because she was typically in bed at the start of the day shift. One staff member reported that, during hand-off report, the night-shift staff member stated in front of the resident and other staff that the resident did not get any water because she would need to get up, and that there was no water near the resident. Staff also reported that the resident stated her call light had not been answered during the night, that she had been told not to call for help, and that she was refused an ice pack. The resident appeared distraught, anxious, and repeatedly questioned why she had been treated that way, requiring frequent reassurance from day-shift staff. The facility’s investigative documentation further detailed that the resident reported being denied water, being told she could not have her call light, and being kept in an “awful” room in an uncomfortable chair. Staff statements indicated that the night-shift staff member moved the resident to the day lounge after the resident got up multiple times without using her call light, purportedly to keep an eye on her. Abuse meeting notes identified concerns that the resident was placed in a recliner in a common area despite asking to return to bed, that this request was dismissed, that an overbed table may have been placed across her to keep her in the recliner, that her walker was moved farther away to limit mobility, and that the resident reported feeling punished. These actions and omissions were determined by the facility’s internal review to constitute abuse under the facility’s abuse policy, which states that each resident has the right to be free from abuse and that the facility is responsible to prevent abuse and neglect.
Failure to Use Gait Belt and Update Fall Care Plans After Repeated Falls
Penalty
Summary
Facility staff failed to ensure safe ambulation practices and adequate supervision, and did not consistently evaluate and modify fall-prevention interventions. In one incident, a resident ambulating with a rolling walker and on supplemental oxygen fell when the assisting staff member turned her back on the resident. The resident was not wearing a gait belt at the time, contrary to facility policy and staff expectations that gait belts be used for all residents requiring assistance with transfers or ambulation. The resident fell backward onto her bottom, struck her left arm and hand on a door jamb, and sustained a skin tear with tendon exposure on the left fourth finger that required nursing treatment. The same resident had multiple additional unwitnessed falls and a near miss over several months. One nursing progress note documented that the resident was ambulating in the hallway while still connected to an oxygen concentrator in her room, tripped on the oxygen tubing, and nearly fell but was caught by a CNA. A list of falls showed several unwitnessed falls and a near miss, indicating repeated events without documented evidence in this report of effective modification of interventions specific to those incidents. Staff interviews confirmed that gait belts were expected for assisted ambulation and that each resident should have their own gait belt, yet staff could not explain why a gait belt was not used during the documented fall. For two other residents with multiple unwitnessed falls, the facility did not update fall care plans to reflect new or revised interventions discussed in weekly fall meetings. One resident experienced numerous unwitnessed falls in her room, bathroom, and another resident’s room, with documented causes such as unsafe gait, dehydration, increased weakness and confusion, new medication, tremors, and sepsis onset. Fall meeting notes listed various potential or actual interventions, including walker use, room changes, supervision, and use of a gait belt, but the fall care plan showed only the later addition of a gait belt and no other changes over several months. Another resident, assessed as high risk for falls and with Parkinson-related freezing, had multiple unwitnessed falls in the bathroom, by the bed, and between a recliner and bed. Fall meeting notes documented causes such as not calling for staff and resistance to asking for help, with suggested interventions like hourly rounding, ensuring wheelchair positioning and locking, and attempting a toileting schedule. However, the fall care plan showed no changes after these events, and staff acknowledged they had not been updating care plans following weekly fall meetings, despite a facility fall-prevention policy stating that interventions may be added to care plans to prevent further falls.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified regarding the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to the risk of accidents for residents. Specific actions or inactions leading to this deficiency include the lack of proper hazard identification and insufficient supervision in the affected area. No additional details about specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Provide Accessible and Anonymous Grievance Process
Penalty
Summary
The facility failed to establish and implement a grievance policy that included instructions for submitting grievances anonymously and did not post the grievance officer's contact information in a prominent location. Two residents reported being unaware of the grievance process, how to file grievances anonymously, or where to find or deposit grievance forms. Observations confirmed the absence of posted information identifying the grievance officer and the required contact details. Additionally, the box available for submitting forms was labeled for 'Suggestions' rather than grievances or complaints, and had previously been repurposed, further contributing to confusion. Interviews with staff revealed that the grievance officer had not processed any resident grievances and that concerns were typically handled verbally without documentation. Staff indicated that residents would need to request a grievance form, which was only available electronically and required staff assistance to print. The facility's written policy on complaints and grievances did not include procedures for anonymous submissions. These actions and omissions resulted in a lack of accessible and clear grievance procedures for residents.
Lack of Documentation for Medical Director Attendance at QAPI Meetings
Penalty
Summary
The facility failed to maintain proper documentation of the Medical Director's or designee's attendance and participation in Quality Assurance and Performance Improvement (QAPI) meetings, which are required to occur at least quarterly. Record review revealed that, except for one documented instance in April 2025, there was no evidence of a medical provider or director attending QAPI meetings from September 2024 to March 2025, and from May 2025 to July 2025. Staff interviews confirmed that while QAPI meetings were held monthly (excluding July and December), there were no sign-in sheets to verify attendance, and the facility relied on meeting minutes to record attendees. Staff also indicated that the Medical Director or designee sometimes attended via video conferencing, but this was not consistently documented. The facility's QAPI policy requires the Medical Director to be a member of the committee and for meetings to occur at least quarterly. Despite requests for sign-in documentation to confirm the Medical Director or designee's attendance at required meetings, no such records were provided during the survey. This lack of documentation means the facility could not demonstrate compliance with regulatory requirements for QAPI committee composition and meeting frequency.
Failure to Follow Infection Control Practices During Medication Administration
Penalty
Summary
Facility staff failed to adhere to proper infection prevention and control practices during medication administration for three of four observed residents. Specifically, a staff member did not perform hand hygiene prior to handling or administering medications to multiple residents. In one instance, a medication was dropped onto the medication cart surface, picked up with a plastic spoon, and placed in a medication cup without hand hygiene being performed or the cart surface being sanitized. Additionally, the staff member was observed touching various surfaces and resident items, such as a call light, water cup, and the resident's hand, without performing hand hygiene before administering medications. Interviews with staff confirmed awareness that hand hygiene should occur before and after resident contact, but review of facility training materials revealed no specific training on infection prevention during medication administration. Facility policies on medication administration and hand hygiene require handwashing before medication preparation and administration, and after contact with inanimate objects or glove use, but these procedures were not followed during the observed incidents.
Failure to Hold Anticoagulant After Critical Lab Value Due to Communication Breakdown
Penalty
Summary
The facility failed to recognize, identify, and confirm with a physician the need to discontinue or hold a Coumadin (warfarin) order for a resident who had a critical lab value. The resident, who had chronic atrial fibrillation and was on chronic anticoagulation therapy, returned from the emergency department with a significantly elevated INR and a large hematoma. Despite documentation in the hospital records to hold Coumadin for one week due to the elevated INR, the medication orders in the long-term care facility's electronic medical record remained unchanged, and the resident continued to receive the medication. Nursing staff did not question the continuation of Coumadin, nor did they contact the provider for clarification, even though the facility's policy required provider notification and holding the medication for elevated INR levels. Interviews with staff revealed a communication breakdown between the hospital and the LTC facility, resulting in the hold order not being transferred to the facility's EMR. Staff acknowledged that critical thinking and nursing judgment were not applied, and the Coumadin order was not included in the investigation of the resident's injury, which was attributed to the use of the sit-to-stand lift and the effects of anticoagulation. The facility's policy required prompt provider notification and action for elevated INR, which was not followed in this case.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to identify and address a resident's history of trauma and associated triggers, resulting in a lack of trauma-informed and culturally competent care. The resident had a documented diagnosis of chronic post-traumatic stress disorder (PTSD), with provider notes indicating ongoing treatment and medication adjustments for PTSD and depression. Interviews revealed the resident had a significant trauma history, including an abusive marriage, the loss of a child, and childhood hospitalization. Staff acknowledged that the resident experienced triggers, such as believing her ex-husband was present at the facility, but there was no recent discussion of her PTSD diagnosis among staff due to staff turnover. Review of the resident's care plan showed it did not include the PTSD diagnosis, nor did it identify specific triggers or interventions to prevent re-traumatization. The resident's Minimum Data Set (MDS) assessment did not indicate PTSD as an active diagnosis, and no trauma-informed care assessment or social history was provided upon request. Staff interviews confirmed there was no process to ensure communication of specialized provider diagnoses to staff, contributing to the lack of trauma-informed care planning for the resident.
Failure to Refer Resident for Replacement of Lost Dentures
Penalty
Summary
The facility failed to promptly refer a resident with lost partial dentures to dental services, resulting in the resident going without his upper partial denture. The resident, who had Alzheimer's disease and severe cognitive loss, was on a pureed diet and expressed dislike for the texture. The loss of the partial denture was discovered when the resident's family came to pick him up for a home visit, and staff informed them that the denture was missing. Documentation showed that the denture was reported missing, and a search was conducted, but there was no evidence that a referral to dental services was made or that replacement was offered. Review of the resident's records indicated a significant weight loss of 15% over six months. The facility's policy stated that it is responsible for lost dentures when the resident is not competent or has dementia. However, staff interviews revealed that some were unaware the denture was missing, and no documentation was provided to show follow-up or referral to dental services before the end of the survey.
Failure to Timely Report Verbal Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of verbal abuse within the required 24-hour timeframe. The incident involved a staff member allegedly verbally abusing a resident before 8:00 a.m. on October 5, 2023, and was reported internally to another staff member at 11:30 a.m. the same day. However, the initial report to the State Survey Agency was not submitted until October 10, 2023, five days after the incident occurred. During an interview, the staff member responsible for submitting abuse allegations to the state was unable to explain the delay, despite being aware of the required reporting timelines. Additionally, the facility's abuse policy, dated August 27, 2023, did not specify the reporting timelines for incidents to the State Survey Agency.
Resident Excluded from Care Plan Meetings
Penalty
Summary
The facility staff failed to include a resident in care plan meetings, which is a deficiency in allowing residents to participate in the development and implementation of their person-centered plan of care. During an interview, the resident expressed that she was not invited to any care plan meetings, although her family members were. The resident indicated a desire to attend these meetings. A review of the resident's electronic medical record showed no documentation of her being invited to participate in her care plan meetings. The resident was assessed as cognitively intact with a score of 13 on the Brief Interview for Mental Status. A staff member responsible for inviting participants to care plan meetings confirmed that she contacts family members but does not document these invitations and acknowledged that the resident had not been invited to her care plan meetings.
Failure to Identify and Document Bilateral Grab Bars as Restraints
Penalty
Summary
The facility failed to identify bilateral grab bars as a potential restraint for a resident and did not complete necessary procedures such as a risk assessment, obtaining consent, or implementing restraint monitoring. During observations, bilateral grab bars were noted on the resident's bed. An interview revealed that consent might have been given due to the resident's history of falling out of bed and sustaining bruises, as well as undergoing head scans due to falls. However, the resident's electronic medical record lacked documentation of a risk assessment, physician's order, or signed consent for the use of the grab bars. The resident was assessed as dependent for turning and repositioning, and staff indicated that the grab bars were not used as an assistive device but rather for hanging the call light and bed controls. The facility's restraint policy stated that restraints would not be used for convenience.
Pharmacist Fails to Monitor Psychotropic Medication Duration
Penalty
Summary
The facility failed to ensure that a licensed pharmacist conducted a proper monthly drug regimen review for a resident receiving as needed psychotropic medication. Specifically, the pharmacist did not monitor a resident who was receiving lorazepam for an excessive duration. The resident's Medication Administration Record (MAR) indicated that lorazepam was administered on two occasions, and the order for this medication had been in place for more than 14 days. During an interview, a staff member was unaware of the prolonged order and noted that the pharmacist had not addressed this issue with the medical provider. The facility's policy required the pharmacist to monitor psychotropic medication use and notify the physician when a review was due, which was not adhered to in this case.
Failure to Limit PRN Psychotropic Medication to 14 Days
Penalty
Summary
The facility failed to ensure that as-needed psychotropic medications were limited to 14 days unless there was provider documentation explaining the rationale for continuing the medication. This deficiency was identified for one resident who had an order for lorazepam, to be taken twice a day as needed for anxiety or shortness of breath. The resident's medication administration record (MAR) showed that lorazepam was administered on two occasions, but the order for the medication remained active beyond the 14-day limit without documented justification from a medical provider. During an interview, a staff member acknowledged being unaware of the ongoing order for as-needed lorazepam beyond the 14-day period. The responsibility for monitoring such orders was attributed to the medication nurse or care coordination nurse. Additionally, the facility's medication regimen reviews, conducted by the pharmacist, failed to identify the prolonged as-needed use of lorazepam, and there was no evidence that the pharmacist contacted the provider to address this issue. The facility's policy on psychotropic medications clearly stated that as-needed orders should be limited to 14 days and used only for specific, documented circumstances.
Inadequate Supervision Leads to Resident Elopement and Injury
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident, resulting in a fall with injury. The resident, who had a history of elopement and periods of confusion, managed to leave the facility without staff awareness. On the day of the incident, the resident was restless and attempted to access the elevator multiple times. Despite staff efforts to redirect him, he successfully exited the building by catching the main door before it latched, leading to a fall in the street where he sustained facial injuries. The resident had a history of elopement, often leaving for the hospital connected to the facility. Staff interviews revealed that the resident was known to be restless and had learned to disable the door alarm system. The facility's Roam Alert System, intended to prevent such incidents, was reportedly unreliable, and staff had become desensitized to its alarms. The resident's elopement risk was documented, but the facility did not foresee his ability to exit the building until the incident occurred. Interviews with staff indicated a lack of clear protocol for 1:1 supervision, which was left to the discretion of the nurse on shift. The resident's care plan acknowledged his elopement risk and included interventions such as a new wander guard system and offering non-alcoholic beers to address his restlessness. However, these measures were insufficient to prevent the elopement and subsequent injury.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
