Sidney Health Center Extended Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Sidney, Montana.
- Location
- 104 14th Ave Nw, Sidney, Montana 59270
- CMS Provider Number
- 275121
- Inspections on file
- 19
- Latest survey
- December 4, 2025
- Citations (last 12 mo.)
- 18 (1 serious)
Citation history
Health deficiencies cited at Sidney Health Center Extended Care during CMS and state inspections, most recent first.
Multiple residents experienced falls resulting in injuries such as fractures and lacerations due to the facility's failure to implement an effective fall prevention program. Staff did not consistently complete required fall checklists, update care plans, or conduct thorough post-fall assessments. Communication about fall risk was inadequate, and staff training on fall prevention interventions was lacking, leading to repeated incidents and insufficient individualized interventions.
The facility did not submit required reports to the State Survey Agency within mandated timeframes for several incidents, including unwitnessed falls with injury and an incident of staff-to-resident abuse. In each case, reports were filed late despite prompt internal notifications and investigations, with staff unable to explain the delays or clarify reporting responsibilities.
The facility did not complete or document thorough investigations for multiple facility-reported events, including unwitnessed falls with injury and a resident-to-resident abuse incident. In each case, only the event submission to the State Survey Agency was available, with no formal investigation files maintained or provided to surveyors.
The facility did not update care plans for several residents after fall incidents, failing to add new interventions or address root causes as required. Multiple residents experienced falls with injuries, but care plans were not revised, event forms were incomplete, and root cause analyses were not performed. Staff interviews indicated unclear processes and communication gaps regarding care plan updates after falls.
Staff physically restrained a resident to administer an IM medication, violating the resident's right to be free from restraint. The staff did not follow the care plan's behavioral interventions, and there was no physician order to hold the resident during the procedure. The facility's investigation confirmed that staff actions contributed to the escalation of the resident's behaviors and substantiated the occurrence of abuse.
The facility failed to provide continuous oxygen to two residents, leading to hypoxic episodes. One resident with severe COPD was found unresponsive without oxygen in the tub room, and another was taken to the dining room without oxygen, resulting in low oxygen levels and seizure-like activity. A second resident on the dementia unit was also found without oxygen, with saturation at 88%. The facility's policy requires a physician's order for oxygen use, but these incidents show a lack of adherence to this standard.
The facility failed to maintain a full-time on-site Director of Nursing (DON), leading to inadequate oversight and negative outcomes in respiratory care for two residents. The interim DON worked on-site for two weeks and remotely for two weeks, resulting in insufficient oxygen saturations due to lack of adherence to professional standards and physician orders.
A resident with dementia was found with bruises of unknown origin, and the facility failed to investigate thoroughly or report the incident to required officials. Despite staff noting the bruises were inconsistent with the facility's explanation, the investigation was limited and lacked proper documentation. The State Survey Agency was not notified, and the investigation did not adequately address the cause of the bruising.
A facility failed to implement a baseline care plan for a resident's oxygen use within 48 hours of admission, resulting in a hypoxic event. The resident had a long history of continuous oxygen use and was admitted with specific oxygen orders, which were not included in the initial care plan. The oversight was only corrected after the resident experienced a hypoxic event.
The facility failed to maintain consistent enhanced barrier precautions for two residents and lacked infection surveillance documentation for six months. Observations revealed missing precaution signs and PPE supplies, while interviews highlighted staff unawareness of precautionary measures. Additionally, the facility did not document infection surveillance or report communicable diseases as required, posing increased risk to residents.
A facility failed to update a comprehensive care plan for a resident using oxygen therapy, despite multiple MDS assessments indicating its necessity. The resident, diagnosed with acute and chronic respiratory failure, pneumonia, and pulmonary hypertension, was observed using oxygen therapy, yet the care plan lacked details on oxygen use, respiratory status, and necessary interventions. This oversight was a repeated failure from admission to the survey date.
The facility failed to update care plans for two residents, leading to deficiencies in their care. A resident who fell and complained of head pain did not have their care plan updated to address fall risks. Another resident with multiple sclerosis requested gait belts for leg support, but their care plan lacked documentation and assessment for the belts' use. Staff admitted to not reviewing or updating care plans, indicating a lack of oversight.
The facility failed to complete POLST forms for three residents, with missing dates, signatures, and contact information. Staff oversight was lacking, as there was no process to ensure forms were completed, and they were only discussed during care plan meetings.
A resident reported a grievance about a nurse's strong perfume odor, which was not documented or resolved by the facility. Despite a policy against strong scents, the issue was only addressed verbally, and staff were unsure of any follow-up actions, indicating a failure to adhere to the grievance policy.
A facility failed to identify and report irregularities in a resident's use of Xanax, a psychotropic medication, beyond the recommended 14-day period without proper documentation. The pharmacist incorrectly deemed the continued use acceptable, and a staff member indicated the physician intended to make it scheduled, but no documentation supported this change. The oversight highlights a failure in the facility's medication management process.
A facility failed to review or discontinue a resident's PRN Xanax after 14 days, as required by policy. The physician's progress note showed uncertainty about the resident's Xanax use, and despite requests, no documentation was provided to justify continued use. The facility's policy mandates PRN orders be limited to 14 days unless extended with documented rationale, which was not received. Staff noted that physician documentation was in a different system, contributing to the issue.
A facility failed to administer the recommended pneumococcal vaccine to a resident, as revealed during interviews and record reviews. The facility's policy was outdated, and staff were unclear about the immunization process. The resident had not received the necessary vaccine dose according to CDC guidelines, and there was no documentation of consent or declination for the vaccine.
Failure to Implement Effective Fall Prevention Program and Inadequate Post-Fall Response
Penalty
Summary
The facility failed to implement and maintain an effective fall prevention program, as evidenced by multiple incidents involving residents who experienced falls resulting in injuries, including fractures and lacerations. In several cases, staff did not complete required fall checklists or event forms, and there was a lack of timely and thorough nursing assessments following fall events. For example, one resident experienced a fall in the bathroom resulting in a rib fracture, but no fall checklist was completed, and there were no nursing progress notes documenting assessments of the resident's condition in the days following the incident. Another resident with a history of multiple falls, cognitive impairment, and high-risk medications experienced several falls, some resulting in head lacerations and bruising. The care plan for this resident was not updated to reflect new risks or interventions after each fall, and interventions such as fall or bed alarms were not considered or implemented. Staff interviews revealed inconsistent understanding and application of fall prevention protocols, and care plans often contained outdated or irrelevant interventions. Additionally, there was a lack of individualized interventions addressing specific risk factors such as incontinence and confusion. Further review showed that staff were not consistently trained or updated on fall prevention interventions, and communication regarding residents' fall risk was inadequate. Assignment sheets and room signage did not reliably indicate which residents were at high risk for falls. In some cases, falls were not investigated or discussed by the interdisciplinary team, and root cause analyses were not completed. Facility policies required comprehensive post-fall management and care plan updates, but these were not consistently followed, resulting in repeated falls and injuries among residents.
Failure to Timely Report Abuse, Neglect, or Injury Events
Penalty
Summary
The facility failed to submit timely reports to the State Survey Agency for multiple reportable events involving suspected abuse, neglect, or injury. In five separate cases, the facility did not meet the required two-hour reporting window for incidents involving serious bodily injury or suspicion of abuse. These included unwitnessed falls resulting in injuries such as a vertebral fracture, and an incident where a resident was held down by staff during medication administration, which led to the termination of two staff members for abuse. In each case, the initial or final reports were submitted late, sometimes by more than a day, despite internal notifications and initiation of investigations occurring promptly after the incidents. Interviews with staff revealed a lack of clarity regarding responsibility and procedures for timely reporting. Staff members acknowledged that reports should be filed as soon as possible, especially in cases of serious injury or abuse, but were unable to explain the delays. In some instances, the responsible staff member was not present in the facility at the time of the incident, and reporting was delayed until their return. The facility's investigation processes were noted to be in need of improvement, as evidenced by the repeated late submissions of required reports to the State Survey Agency.
Failure to Investigate and Document Facility-Reported Events
Penalty
Summary
The facility failed to conduct thorough investigations and maintain comprehensive documentation following facility-reported events for three residents. In one case, a resident experienced an unwitnessed fall resulting in a significant injury, including a fracture of the S5 vertebrae, and was treated in the ER. Despite the seriousness of the injury and the resident being an unreliable reporter, the facility did not provide an investigation file when requested by surveyors. In another instance, a resident was involved in a resident-to-resident abuse incident where they were pinched by another resident, but again, no investigation file was available for review. Additionally, a third resident sustained an unwitnessed fall with injury and was treated in the ER. Documentation revealed that no investigation was conducted for this incident, as the DON was not present in the facility at the time and did not initiate an investigation upon return. The only documentation available for these events was the submission of the event to the State Survey Agency, with no formal investigation files maintained. Interviews with staff confirmed the lack of investigation and documentation for these incidents.
Failure to Update Care Plans After Falls
Penalty
Summary
The facility failed to update and revise care plans for multiple residents following fall events, as required by policy and regulatory standards. For four residents, care plans were not updated to reflect new interventions or to address the root causes of falls, even after incidents that resulted in injuries. In several cases, fall safety event forms were not completed, and there was no documentation of root cause analyses or evaluation of existing interventions. For example, one resident experienced a fall resulting in a rib fracture while on anticoagulant medication, but the care plan was not updated to reflect this risk or to include new interventions. Another resident had an unwitnessed fall, but the care plan was not reviewed or revised, and the event remained open without a root cause analysis for over a month. Additionally, two other residents experienced multiple falls with injuries within a short time frame, yet their care plans showed no updates or new interventions in response to these incidents. Staff interviews revealed confusion regarding responsibility for updating care plans after falls, and there was a lack of clear communication about care plan changes to direct care staff. The facility's own fall prevention policy required care plan review and updates after any fall, but this process was not consistently followed, as evidenced by the lack of documentation and intervention updates in the residents' records.
Failure to Prevent Abuse and Use of Physical Restraint During Medication Administration
Penalty
Summary
Facility staff held a resident down to administer an intramuscular (IM) medication due to the resident's behaviors, which constituted a violation of the resident's right to be free from physical restraint. The staff's actions were not in accordance with the resident's care plan, as the behavioral interventions outlined in the care plan were not followed. Documentation indicated that staff attempted three interventions—offering food, assessing pain, and playing music—before administering the medication, but only the pain assessment was a care plan intervention, and there was no evidence that it resulted in an actual intervention such as administering pain medication. Additionally, offering food and music were not listed in the care plan as interventions. The facility's investigation substantiated that abuse occurred and found that staff interactions contributed to the escalation of the resident's behaviors. The resident's behaviors did not pose an immediate risk of harm to herself or others at the time of the incident. There was also no physician order authorizing staff to physically restrain the resident during medication administration. The incident was reported to the State Survey Agency, and the facility's investigation confirmed that the staff failed to follow established protocols and care plan interventions, resulting in the substantiated finding of abuse.
Failure to Provide Continuous Oxygen to Residents
Penalty
Summary
The facility failed to provide necessary respiratory care and services to two residents, leading to insufficient oxygen saturations. One resident, who had severe COPD and was oxygen-dependent, experienced a hypoxic episode in the tub room without her oxygen on. Staff member M applied oxygen and called the physician after the resident turned blue and was unresponsive. The resident's care plan did not initially include oxygen use, and it was only revised after the incident. Another incident involved the same resident being taken to the dining room without oxygen, resulting in low oxygen levels and seizure-like activity. The CNA responsible was new and reportedly not educated on which residents required oxygen. Another resident was found without oxygen on the dementia unit, with an oxygen saturation of 88%. Staff member N applied oxygen immediately, and the resident's levels returned to baseline. The facility's policy on oxygen administration requires a physician's order for its use, but the incidents indicate a failure to adhere to these standards, as both residents were found without their prescribed continuous oxygen.
Deficiency in Full-Time On-Site Director of Nursing
Penalty
Summary
The facility failed to ensure that a Director of Nursing (DON) was working full-time for 35 or more hours per week on-site, which increased the risk of negative outcomes for all residents due to the lack of onsite oversight. This deficiency was identified during a survey where harm was noted in the area of respiratory care and services, affecting two residents who experienced insufficient oxygen saturations. The facility had been unable to hire a permanent DON and had contracted an interim DON who worked on-site for two weeks and then remotely for two weeks. Observations during the survey confirmed the absence of the DON on several occasions, which contributed to the failure in providing necessary respiratory care and services in accordance with professional standards and physician orders.
Failure to Investigate and Report Bruising of Unknown Origin
Penalty
Summary
The facility failed to adequately respond to allegations of abuse concerning a resident who was found with bruises of unknown origin. The resident, who had dementia and required assistance for toileting, was noted to have dark purple and red bruising on her buttocks and thighs. Despite the bruising being reported to facility management, there was no evidence that the incident was thoroughly investigated or that it was reported to the required officials. The initial assessment by a staff member indicated that the bruising was higher than where a toilet seat would typically cause such marks, contradicting the facility's event report that suggested the bruises were from sitting down hard on the toilet. Interviews with staff revealed inconsistencies and a lack of thorough investigation into the cause of the bruising. One staff member mentioned that another staff member had found the resident on the floor, but this was not further investigated. Additionally, the State Survey Agency was not notified about the bruises, and the investigation only included interviews with four staff members, which were not dated to indicate when the investigation began. The lack of a comprehensive investigation and failure to report the incident to the appropriate authorities contributed to the deficiency.
Failure to Implement Baseline Care Plan for Oxygen Use
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a resident's oxygen use within 48 hours of admission, leading to a hypoxic event. The resident, who had been using oxygen continuously for many years prior to admission, was admitted with a physician's order for oxygen at 2-4 liters per minute via nasal cannula to maintain SaO2 at 90% or above. This order was later adjusted to titrate oxygen as needed to keep SaO2 at 88% or above, with the resident currently on 4 liters continuously. However, the baseline care plan did not include any problems, goals, or interventions for oxygen use. The omission was identified after the resident experienced a hypoxic event, and the oxygen usage was only added to the care plan post-incident. Staff acknowledged the oversight but indicated there was nothing that could be done about it after the fact.
Inconsistent Infection Control Practices and Documentation Lapses
Penalty
Summary
The facility failed to ensure consistent enhanced barrier precautions for two residents, which was identified through observations and interviews. Resident #37's door had a yellow isolation bag with gowns, gloves, and wipes, but lacked a precaution sign. Similarly, staff member M was unaware of the reason for an enhanced barrier precaution sign on resident #16's door, and no PPE supplies were found in the room or bathroom. These observations indicated a lack of proper communication and availability of necessary infection control supplies for residents under enhanced barrier precautions. Additionally, the facility did not provide documentation of infection surveillance and mandatory communicable disease reporting for six consecutive months. Staff member L, who had recently returned from medical leave, acknowledged the absence of surveillance tracking from March to August 2024. The facility's infection control program, which should include a system for prevention, identification, reporting, investigation, and control of infections, was not adequately maintained during this period. The facility's policies required healthcare providers to report confirmed or suspected cases of communicable diseases to the local health department. However, the lack of updated documentation and surveillance tracking suggests that these procedures were not followed. This deficiency in infection control practices posed an increased risk to the entire facility population.
Failure to Update Care Plan for Oxygen Therapy
Penalty
Summary
The facility failed to ensure a comprehensive person-centered care plan was created for a resident who utilized oxygen therapy. Despite the resident having three MDS assessments completed, all indicating the use of oxygen therapy, the care plan was never updated to reflect this need. This oversight was observed from the resident's admission and continued through multiple assessments, demonstrating a repeated pattern of failure. The resident's electronic medical record showed pertinent diagnoses, including acute and chronic respiratory failure with hypoxia, pneumonia, and pulmonary hypertension, yet these were not adequately addressed in the care plan. Observations and interviews confirmed the resident's ongoing use of oxygen therapy, with a nasal cannula connected to an oxygen concentrator set at 3 liters. However, the comprehensive care plan, revised shortly before the survey, lacked any mention of the resident's oxygen use, respiratory status, or necessary interventions. The care plan did not include problems, goals, or interventions related to oxygen use, nor did it provide guidance on oxygen saturation levels, flow rates, precautions, or equipment management. This deficiency was noted as a repeated failure from the time of the resident's admission to the date of the survey.
Failure to Update Care Plans for Fall Prevention and Gait Belt Usage
Penalty
Summary
The facility failed to review and revise the individualized care plans for two residents, leading to deficiencies in their care. Resident #10 experienced a fall on 11/30/23, resulting in head pain. The facility did not identify the root cause of the fall, and the care plan was not updated to address the risk of nighttime falls or toileting needs until 7/8/24. Staff member F admitted to not reviewing or updating the care plan after the fall, indicating a lack of oversight and stability in the care planning process. Resident #4, who has multiple sclerosis, requested the use of gait belts to hold her legs together while in a wheelchair due to muscle weakness. However, the care plan did not address the use of these gait belts, nor did it include a restraint assessment or guidelines for their use. Staff member I confirmed that the application of the gait belts was not documented in the care plan. The facility's policy requires comprehensive care plans to be periodically reviewed and revised, but this was not done for resident #4, resulting in a lack of documented interventions and assessments related to the gait belt usage.
Incomplete POLST Forms for Residents
Penalty
Summary
The facility failed to ensure that Provider Orders for Life-Sustaining Treatment (POLST) forms were properly completed for three residents. For one resident, the POLST form was not dated when signed by the resident's legal decision maker. Another resident's POLST form lacked the printed name, telephone number, and dates indicating when the form was prepared and signed. Similarly, a third resident's POLST form was missing the printed name, telephone number, and dates showing when the form was prepared and completed by the medical provider. Interviews with staff revealed a lack of oversight and process in ensuring POLST forms were completed. Staff member K, who was responsible for overseeing POLST forms and advance directives, admitted to not checking the forms when another staff member started filling them out. There was no established process to ensure the completion of POLST forms, and they were only discussed during individual resident care plan meetings. The facility's policy on advance directives indicated that residents should be informed of their rights to make medical decisions, but no specific POLST policy was provided during the survey.
Failure to Investigate and Resolve Resident Grievance on Strong Perfume Odor
Penalty
Summary
The facility failed to fully investigate and resolve a grievance reported by a resident regarding a strong perfume odor from a nurse, which was causing discomfort. The resident expressed concern about the potential impact on other residents with respiratory issues. This grievance was raised during a care planning meeting attended by staff members, but the resident did not receive any follow-up regarding the issue. Interviews with staff revealed that the facility had a policy against strong scents, allowing only lightly scented deodorant and laundry soap. Despite this policy, there was no written documentation of the grievance, and the issue was only addressed verbally. Staff members were unsure if any follow-up actions had been taken, indicating a failure to adhere to the facility's grievance policy, which requires prompt investigation and documentation of grievances.
Failure to Identify and Report Medication Irregularities
Penalty
Summary
The facility failed to ensure that the monthly drug regimen review process was effectively used to identify and report irregularities in medication use for a resident. Specifically, the pharmacist did not recognize a problem with the continued use of Xanax, a psychotropic medication, beyond the recommended 14-day period without proper documentation from the attending physician. The facility's policy on psychotropic medication management requires that PRN orders for such drugs be used only for a diagnosed specific condition and for a limited duration unless the physician provides a documented clinical rationale for extending the order. However, in this case, the pharmacist incorrectly deemed the continued use of Xanax acceptable, stating that it was not an antipsychotic and thus could be used beyond 14 days. The deficiency was further highlighted during an interview with a staff member responsible for tracking psychotropic drug use and notifying physicians of medication irregularities. The staff member indicated that the resident was allowed to continue using Xanax as needed because the physician intended to make it a scheduled medication. However, there was no documentation from the physician to support this change, and the as-needed Xanax had been refilled five times without the necessary documentation. This oversight indicates a failure in the facility's process to ensure compliance with its own policies and procedures regarding psychotropic medication management.
Failure to Review or Discontinue PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure that an as-needed psychotropic medication, Xanax, was reviewed or discontinued after 14 days for a resident. The resident's physician progress note indicated uncertainty about whether the resident had been using Xanax regularly or only as needed. Despite requests for medical provider documentation on the continued use of Xanax, no additional information was received by the end of the survey. The facility's policy on psychotropic medication management requires that PRN orders for psychotropic drugs be used only when necessary for a diagnosed condition and for a limited duration of 14 days unless extended with documented clinical rationale. However, the facility did not receive the necessary physician justification for the continued use of Xanax. Staff member D, responsible for tracking psychotropic drug use, noted that the physician documented notes in a different computer system than the one used by the extended care center, contributing to the lack of information.
Failure to Administer Pneumococcal Vaccine
Penalty
Summary
The facility failed to provide standard infection control practices by not ensuring that a resident received the recommended pneumococcal immunization. During interviews, it was revealed that the facility's pneumococcal policy was in the process of being updated, but the person responsible for this task had left the facility. Staff members were unclear about the exact process for maintaining immunization records, and it was noted that immunization status was only checked upon request. The facility had access to imMTrax for reviewing immunization statuses, but this was not routinely utilized. Resident #34's Preventive Health Care Report indicated that the resident was not current on her pneumococcal vaccination, having last received the PCV13 vaccine in 2018. According to CDC guidelines, the resident should have received a dose of PCV20 or PPSV23 at least one year after the PCV13 vaccine. The facility's policy required that residents or their legal representatives receive education about immunizations and have the opportunity to receive them unless contraindicated or refused. However, no documentation was provided for the resident's pneumococcal immunization consent or declination, indicating a lapse in following the facility's policy.
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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