Skyline Heights Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Billings, Montana.
- Location
- 1807 24th St W, Billings, Montana 59102
- CMS Provider Number
- 275020
- Inspections on file
- 34
- Latest survey
- April 23, 2026
- Citations (last 12 mo.)
- 22 (1 serious)
Citation history
Health deficiencies cited at Skyline Heights Nursing And Rehabilitation during CMS and state inspections, most recent first.
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.
Two residents were not adequately informed or educated when their incontinence products were changed to smaller, reusable liners. Both expressed frustration and increased accidents, and staff could not provide documentation of individualized education or explanations regarding the change.
A resident experienced an unwitnessed fall with injury, and the facility failed to submit the investigation findings to the State Survey Agency within the required five-day period. The staff member responsible for reporting was filling in for another and was not educated on the reporting requirements, resulting in a two-day delay.
The facility did not update the comprehensive care plans for two residents after changing their incontinence products from disposable to reusable liners. Both residents expressed dissatisfaction with the new products, reporting increased accidents, but their care plans were not revised to reflect the new interventions, education provided, or the residents' concerns.
A resident with diabetes and neuropathy developed a foot ulcer that was not properly identified, documented, or treated by facility staff despite physician identification and a history of toe wounds. Weekly skin assessments failed to note the wound, prescribed treatments were not administered as ordered, and communication with wound care providers was inadequate. Delays and omissions in care led to the wound worsening, ultimately resulting in hospitalization and amputation of the resident's right great toe.
A resident with diabetes and neuropathy developed new foot wounds, but the facility did not update the care plan to reflect the resident's history of foot sores or provide preventative interventions for diabetic foot ulcers. The care plan was not revised to include the diagnosis or specific interventions for the ulcer until months after the issue was identified, leaving staff without clear guidance for care.
Nursing staff did not identify, assess, or document a diabetic foot ulcer for a resident, despite a physician's note and ongoing risk factors. Weekly skin checks failed to detect the ulcer, and prescribed wound care was not administered. Staff interviews revealed inconsistent assessment practices and a lack of formal wound care training. The resident was ultimately hospitalized and required amputation of the great toe due to lack of early identification and treatment.
Three newly admitted residents did not receive timely antibiotic and pain medications due to failures in the facility's pharmacy delivery, medication management, and communication systems. One resident with chronic pain and infection received no medications and left against medical advice, another missed IV antibiotics and was re-hospitalized, and a third experienced untreated pain and infection, leading to an ER transfer. Staff interviews confirmed delays, lack of medication availability, and inadequate documentation.
The facility failed to ensure that newly admitted residents received their prescribed medications, including pain management and antibiotics, due to missing or delayed medication orders and lack of medication availability. As a result, three residents did not receive essential medications, leading to unmanaged pain, missed antibiotic therapy, and transfers back to the hospital.
The facility failed to provide physician-ordered medications at the prescribed dose and frequency for several residents, leading to one resident discharging against medical advice, another being re-hospitalized due to missed IV antibiotics, and a third experiencing opioid withdrawal after not receiving pain medication. Staff interviews revealed ongoing pharmacy delays, lack of medication availability, and insufficient training on medication dispensing systems.
Several residents were served meals that did not match the facility's planned menu, with vegetables omitted and unapproved substitutions made. Some residents received food items they disliked or that were not listed on their meal tickets, and multiple residents reported the food was unpalatable. Staff interviews confirmed that a new cook was unfamiliar with the menu and that proper monitoring of meal service was lacking.
Nursing staff did not properly document or manage the care and removal of a PICC line for a resident, resulting in missed IV antibiotic doses, lack of documentation regarding the PICC line's presence and removal, and failure to follow established procedures. The resident experienced pain, pulled out the PICC line, and required emergency room care for pain management and line replacement.
The facility failed to provide adequate wound care and documentation for two residents, leading to deficiencies in pressure ulcer management. A resident's foot dressing was not changed as ordered, and her heel was not offloaded as required. Another resident developed a Stage III pressure ulcer, with inconsistent documentation and treatment. The facility did not adhere to physician orders, and staff interviews revealed confusion about care protocols.
The facility experienced significant staffing shortages, resulting in delayed response to call lights and inadequate personal care for residents. Multiple residents reported long wait times for assistance, leading to feelings of neglect and discomfort. The lack of sufficient staff also impacted the ability to provide regular bathing and personal care, with some residents receiving only one bath since admission. High turnover in nursing management and reliance on temporary staff further contributed to the challenges in maintaining quality care.
The facility failed to properly label and dispose of medications and medical supplies, with opened and undated vials and expired items found in various units. Staff interviews revealed inconsistencies in monitoring responsibilities, indicating a systemic issue in medication management.
The facility failed to maintain an effective QAPI system to address staffing, resident showers, and infection control issues. The QAPI plan was incomplete, lacking specific processes and time frames for improvement. Staff turnover in nursing management positions led to inconsistent management of staffing and infection control measures, disrupting the implementation of corrective actions.
The facility failed to follow a care plan by not placing a gel cushion on a resident's recliner, leading to a pressure ulcer. Additionally, another resident's care plan was not updated to include enhanced barrier precautions for an indwelling catheter. Staff confirmed the necessity of these interventions, but they were not implemented.
The facility failed to provide necessary dental services for three residents, resulting in discomfort and embarrassment. One resident had a missing tooth and another required a crown, while two residents had ill-fitting dentures. Despite their complaints, no dental appointments or referrals were documented.
The facility failed to adhere to physician-ordered therapeutic diets for several residents, including those on renal and carbohydrate-controlled diets. Residents reported being served inappropriate foods, such as high sugar and high carbohydrate items, and staff admitted to a lack of understanding and training on therapeutic diets.
The facility failed to consistently implement enhanced barrier precautions, as staff did not adhere to PPE protocols during wound and catheter care for several residents. Observations and interviews revealed that staff often used only gloves, neglecting gowns, despite facility policies requiring both for certain care activities. Additionally, staff lacked adequate training on proper PPE use, increasing infection risks.
A resident was found with multiple medications, including a controlled substance, left at her bedside, despite her evaluation only permitting self-administration of inhalers. Staff interviews revealed a lack of adherence to facility policies on medication management and self-administration, with no staff education provided on the matter.
A facility failed to create a comprehensive baseline care plan for a resident admitted after hospitalization for pneumonia. The resident, who began physical therapy soon after admission, had a care plan that did not address respiratory support and rehabilitation therapy services. This oversight was contrary to the facility's policy requiring the inclusion of physician orders and therapy services in baseline care plans.
Two residents experienced inadequate bathing and repositioning care, with one resident receiving only one shower since admission and no bed baths, despite being dependent on staff due to surgical wounds. Another resident, who preferred showers every two days, also received only one shower. Staff cited time constraints and workload issues as reasons for not completing all necessary tasks.
A resident's PICC line dressing was not changed as per physician orders, leading to the line being pulled out and replaced with an IV port. Staff admitted to being overwhelmed and unable to complete all tasks, resulting in the oversight. Facility guidelines for maintaining sterile dressings were not followed.
A resident with acute respiratory failure and airway obstruction did not receive prescribed nebulizer treatments in the facility. Despite having a physician's order for treatments every four hours, the resident reported worsening breathing and no treatments were administered or documented. Staff confirmed the absence of a nebulizer machine and lack of treatment documentation.
A facility failed to ensure a licensed pharmacist adequately addressed and documented the monthly medication regimen review for a resident on four psychotropic medications. Despite requests for an appropriate diagnosis for Olanzapine and consideration of gradual dose reduction, no changes were made. Staff acknowledged the pharmacy's failure to track medications and follow up on recommendations.
The facility failed to implement or document gradual dose reductions (GDR) for psychotropic medications for three residents. Despite care plans and medication reviews, no GDRs were attempted or documented as contraindicated. Staff interviews revealed issues with the pharmacy's tracking and recommendations, and the facility's policy on GDRs was not followed.
The facility failed to ensure residents' immunizations were up to date per CDC recommendations, affecting three residents. One resident had received two pneumococcal vaccines but required an additional one, while two others had no vaccines administered, despite refusals noted in facility documents. Staff interviews revealed inconsistencies in tracking and inputting immunizations, with reliance on residents' statements and lack of clinical oversight, leading to potential missed vaccinations.
A resident returning from the hospital for bronchitis experienced a five-day delay in starting prescribed medications due to the facility's failure to timely transcribe and initiate physician orders. Staff interviews revealed a lack of a clear process for handling new medication orders, compounded by inconsistent nurse staffing and management turnover. The facility's policy required timely communication and administration of medications, which was not effectively followed.
The facility failed to provide necessary ADL assistance for dependent residents, resulting in significant gaps in bathing and grooming. A resident reported not receiving a shower for over four weeks, despite being scheduled for twice-weekly showers. Another resident, dependent on staff for hygiene due to physical limitations, went 25 days without a shower. A third resident experienced long periods without bathing, feeling unclean due to staff being too busy. A staff member confirmed that some scheduled showers were missed due to workload.
A facility failed to supervise a resident with severe cognitive impairment during a medical appointment, leaving them unattended at a clinic. The resident, diagnosed with dementia and at risk for wandering, was transported by a facility employee but left unsupervised, contrary to their care plan. Staff interviews confirmed the lack of supervision, with one staff member acknowledging the need for supervision due to the resident's condition.
A resident with a known allergy to silicone catheters developed a rash after a suprapubic catheter replacement with a silicone catheter due to unavailable supplies. The nurse was unaware of the allergy and did not notify the medical provider immediately after the catheter change, leading to a delay in addressing the allergic reaction.
The facility failed to ensure food was served in a sanitary manner and did not practice proper hand hygiene while serving meals between residents. Staff members were observed eating and drinking in the tray line area and serving trays without performing hand hygiene between each meal delivery, despite having received training on these practices.
A resident identified with weight loss did not receive assistance with meals, as observed on multiple occasions. The resident's meal tray remained untouched while she was asleep, and staff were unaware of her dietary needs. Record reviews indicated the resident required meal setup and assistance, but these needs were not met.
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 Inform and Educate Residents on Incontinence Product Changes
Penalty
Summary
The facility failed to adequately inform and educate residents regarding a change in incontinence treatment and products. Two residents experienced a switch from their previous incontinence products to smaller, reusable liners without receiving a clear explanation or individualized education about the reasons for the change. One resident expressed frustration and sadness, noting increased accidents and dissatisfaction with the new products, while another questioned whether they could purchase their preferred products independently. Both residents reported that staff did not provide sufficient information about the change, and documentation confirming resident education was not available. Staff interviews revealed that the facility had discussed general information about skin breakdown and moisture management during a resident council meeting, but there was no evidence of individualized education or documentation provided to the affected residents. Review of care plans and physician orders indicated that residents had preferences for certain incontinence products, but the facility did not document any education or risk/benefit discussions related to the new products. The lack of communication and documentation led to resident frustration and a lack of understanding about their care changes.
Late Submission of Facility Reported Incident Findings
Penalty
Summary
The facility failed to submit the findings of a Facility Reported Incident involving a resident who suffered an unwitnessed fall with injury to the State Survey Agency within the required five-day deadline. The findings were submitted two days late. Staff interviews revealed that the staff member responsible for submitting the findings was filling in for another staff member who was out of state at the time of the incident. The substitute staff member acknowledged missing the deadline and submitted the findings as soon as she realized the requirement. Additionally, it was confirmed that no education had been provided to the substitute staff member regarding the reporting requirements related to this event. Facility policy requires the administrator to report the results of the investigation to government agencies within five working days of the incident.
Failure to Update Care Plans After Changes in Incontinence Products
Penalty
Summary
The facility failed to update the comprehensive care plans for two residents following changes in their incontinence care interventions. Both residents reported dissatisfaction with the new reusable liners provided, stating that these products were less effective and resulted in more frequent accidents. One resident indicated that they were no longer participating in care planning discussions, despite having previously done so. Staff confirmed that care plans should reflect all incontinence products tried and any changes made, but the documentation did not include the recent switch to reusable liners or the residents' feedback regarding their effectiveness. Record reviews showed that the care plans for both residents had not been revised to include updated interventions, education provided about the risks and benefits of the new incontinence products, or the facility's decision to change the products. The care plans only referenced previous interventions and did not document the residents' current experiences or the facility's recent changes in incontinence management. This lack of timely and accurate care plan updates failed to address the residents' needs and preferences as expressed during interviews.
Failure to Identify, Document, and Treat Diabetic Foot Ulcer Resulting in Amputation
Penalty
Summary
A facility failed to properly identify, assess, document, and treat a diabetic foot ulcer for a resident with a history of diabetes, neuropathy, and previous toe wounds. The physician initially identified a wound on the resident's right great toe in June, but the facility did not document or add this wound to the resident's diagnoses or care plan until several months later. Despite the resident's high risk for skin breakdown and a documented history of toe wounds, the care plan and interventions were not updated in a timely manner to address the new ulcer. Weekly skin assessments conducted by nursing staff repeatedly failed to identify or adequately document the right great toe wound, even after it was noted by the physician. There were inconsistencies and omissions in the administration of prescribed treatments, such as Mupirocin ointment, which was not administered as ordered in June and July. When the resident was sent to a wound care clinic, the facility failed to provide necessary documentation or communicate the specific concerns, resulting in the clinic being unaware of the wound and unable to provide targeted care. Additionally, there were delays in implementing wound care orders, with a nine-day gap between the order for Thera honey and PolyMem dressings and the start of treatment. Throughout the course of the resident's care, there was a lack of effective communication and follow-through among facility staff regarding the resident's wound status and treatment needs. Progress notes, skin assessments, and notifications to providers were incomplete or missing, and the resident's worsening condition was not promptly addressed. The failure to identify, monitor, and treat the diabetic ulcer led to the deterioration of the wound, resulting in hospitalization and amputation of the resident's right great toe.
Failure to Develop and Implement Comprehensive Care Plan for Diabetic Foot Ulcer
Penalty
Summary
The facility failed to ensure that a comprehensive care plan was developed and implemented to address a resident's diabetic foot ulcer and history of foot wounds. Documentation showed that the resident, who had a history of diabetes, neuropathy, and previous toe wounds, presented with new open and scabbed areas on the right toes. Despite these ongoing and new issues, the care plan did not reflect the resident's history of foot sores or provide specific preventative interventions for diabetic foot ulcers. The care plan was not updated to include the diagnosis of a diabetic ulcer until several months after the condition was identified, and interventions specific to the ulcer were only added after a significant delay. Interviews with staff revealed that nurses were responsible for updating care plans when new issues were identified, and that preventative measures should be included in the care plan. However, the care plan for this resident lacked documentation of the resident's history of foot problems and did not guide staff on preventative care for diabetic foot ulcers. Staff also indicated that changes to care plans were communicated during shift reports, but the care plan still failed to include necessary information to direct care for the resident's ongoing and current foot issues.
Failure to Identify and Manage Diabetic Foot Ulcer Leads to Amputation
Penalty
Summary
Facility staff failed to ensure that nurses and nurse aides possessed the necessary competencies and skills to identify, assess, document, and monitor a diabetic ulcer for one resident. Despite a physician's note documenting a diabetic ulcer on the resident's right great toe, weekly head-to-toe skin checks performed by facility staff throughout July failed to identify any skin issues. The first documentation of a skin alteration on the right great toe did not occur until early August, well after the physician's initial identification. Additionally, the medication administration record for July and August did not show evidence that staff administered the prescribed Mupirocin ointment as ordered by the physician. Interviews with staff revealed inconsistent practices and a lack of formal wound care training among nursing staff. One staff member admitted that skin issues might be missed depending on the thoroughness of the assessment and noted that formal wound care training was lacking, aside from wound vac training. Documentation and follow-up with the physician were also insufficient, as there was no evidence of ongoing monitoring or communication regarding the resident's diabetic foot ulcer after its initial identification. Ultimately, the resident required hospitalization and amputation of the right great toe after a wound care appointment, due to the facility's failure to provide necessary services for early identification, ongoing treatment, and preventative interventions.
Failure to Provide Timely Antibiotic and Pain Medication to Newly Admitted Residents
Penalty
Summary
The facility failed to ensure that newly admitted residents received necessary antibiotic and pain medications in a timely manner, resulting in neglect of care for three out of four recently admitted residents. One resident with a history of chronic pain, pneumonia, and sepsis did not receive any of his prescribed medications, including pain management and blood clot prevention, during his stay. This resident and his family expressed dissatisfaction with the lack of care, leading to his discharge against medical advice. Documentation showed that medication orders were entered into the electronic medical record, but no medications were administered, and there was a lack of nursing notes addressing the issue. Another resident, admitted for treatment of a septic shoulder and MRSA bacteremia, was supposed to receive IV antibiotics but missed two doses due to the facility's failure to provide the medication. The resident was not seen by staff until the following day and was subsequently sent back to the hospital for necessary antibiotic treatment. Staff interviews revealed that the antibiotics were not available, and the nurses on duty were not able to mix the medication, further delaying care. A third resident, admitted with cellulitis, abscesses, and narcotic dependence, did not receive ordered IV antibiotics or adequate pain management. The resident experienced significant pain and distress, ultimately pulling out her own PICC line and requiring transfer to the emergency room. Documentation and staff interviews indicated that medication orders were not entered in a timely manner, backup medication systems were not accessed appropriately, and communication with the pharmacy was insufficient. The resident also experienced opioid withdrawal symptoms due to missed pain medication doses. These deficiencies were linked to issues with the facility's pharmacy delivery program, oversight, and medication management systems.
Failure to Provide Timely and Necessary Medications to Newly Admitted Residents
Penalty
Summary
The facility failed to ensure that necessary medications were available and administered to newly admitted residents, resulting in significant medication errors for three out of four sampled residents. One resident was admitted with diagnoses including pneumonia, sepsis, and chronic pain, but did not receive any of his prescribed medications, including pain management and maintenance drugs, from admission to discharge. Nursing staff confirmed that no medications were entered into the electronic medication administration record, and the resident left the facility against medical advice due to not receiving medications. Another resident, admitted for treatment of a septic shoulder and bacteremia, was supposed to receive intravenous antibiotics as part of their care plan. However, the resident did not receive any doses of the ordered IV antibiotic, cefazolin, before being discharged back to the hospital. Staff interviews revealed that the antibiotics were not available and the resident was sent back to the hospital because the necessary medication could not be provided in a timely manner. A third resident, admitted with cellulitis, abscesses, and narcotic dependence, did not receive ordered IV antibiotics or pain medications upon admission. The medication administration record showed missed doses of vancomycin and linezolid due to lack of availability in the facility’s backup supply system. Staff reported delays in entering medication orders and issues with pharmacy communication, resulting in the resident experiencing pain, opioid withdrawal symptoms, and requiring transfer to the emergency room for further management.
Failure to Provide Timely Physician-Ordered Medications Resulting in Adverse Resident Outcomes
Penalty
Summary
The facility failed to provide physician-ordered medications at the prescribed dose and frequency for multiple residents, resulting in significant negative outcomes. One resident was admitted following hospitalization, but no medications were administered after admission due to the absence of available medications. The resident ultimately discharged against medical advice because the facility failed to administer any medications. Staff interviews confirmed that medications were not available and that there have been recurring issues with medications being delayed or stuck at other locations. Another resident, who required IV antibiotics for a septic shoulder and MRSA bacteremia, did not receive any doses of the prescribed antibiotic after admission. The medication administration record showed missed doses, and the resident was sent back to the hospital due to the inability to provide the necessary IV antibiotics. Staff interviews revealed ongoing pharmacy issues, lack of timely medication delivery, and that the nursing staff present were not able to mix the IV medications as required. A third resident did not receive any doses of IV Vancomycin as ordered and experienced opioid withdrawal symptoms due to the unavailability of hydrocodone. The resident became anxious and in pain, ultimately pulling out her own PICC line. Staff reported difficulties in obtaining the narcotic from the pharmacy, lack of training on the medication dispensing system, and delays in medication delivery due to pharmacy processes and external factors such as weather. Additional issues included medication storage errors and communication breakdowns between nursing and pharmacy.
Failure to Follow Menu and Provide Palatable, Appropriate Meals
Penalty
Summary
The facility failed to provide palatable food, follow the established menu, and ensure that residents received the foods specified on their meal tickets. During meal observations, several residents were served mashed potatoes with brown gravy, macaroni salad, and a meat or chicken salad, instead of the vegetable medley and grapes listed on the menu. Multiple residents did not receive a vegetable with their meal, and some expressed dissatisfaction with the taste of the food. One resident did not receive a vegetable and was served food items she did not like, as indicated on her meal ticket. Another resident was served a meal with overcooked pasta and a pale, mushy tomato meat sauce, despite her meal ticket indicating she did not like pasta or carrots. Staff interviews revealed that a new cook, unfamiliar with the facility's menu requirements, substituted mashed potatoes for vegetables without proper authorization or menu guidance. Staff acknowledged that the correct menu was not followed and that monitoring of meal service was inadequate. The diet extension menu did not list mashed potatoes and gravy as an approved substitute for any therapeutic diets or texture alterations, further indicating that the menu was not properly adhered to during meal service.
Failure to Document and Manage PICC Line Care and Removal
Penalty
Summary
Nursing staff failed to provide care for a resident with a peripherally inserted central catheter (PICC) line according to acceptable standards of practice. The resident's medication administration record did not indicate that IV antibiotics were being administered via the PICC line as ordered, and medications were not entered in a timely manner, resulting in missed doses. The resident subsequently pulled out her own PICC line after admission, but there was no documentation in the nursing progress notes regarding the presence of the PICC line or its removal by the resident. Interviews with staff revealed that the resident experienced pain and anxiety, and that the removal of the PICC line should have been documented in the electronic health record, but was not. Additionally, the facility failed to follow established procedures for PICC line removal, including assessment, notification of the physician, and documentation. The lack of documentation and failure to adhere to standards of practice led to the resident returning to the emergency room for pain management and PICC line replacement.
Deficiencies in Pressure Ulcer Management and Documentation
Penalty
Summary
The facility failed to ensure proper wound care and documentation for two residents, leading to deficiencies in pressure ulcer management. Resident #11's foot dressing was not changed as per physician orders, and the resident reported increased pain and worsening of her condition. Observations revealed that the dressing was wrapped tightly and had not been changed as scheduled. Additionally, the resident's heel was not offloaded using a Prevalon Boot as ordered. Staff interviews indicated uncertainty about the timeline of the resident's wounds and a lack of understanding of wound terminology, contributing to inadequate care. Resident #13 developed a Stage III pressure ulcer on her right medial buttock, which was not consistently documented or treated according to physician and hospice orders. The facility was responsible for changing the dressing five days a week, but there was no documentation of dressing changes for a 25-day period. Observations showed that the resident's recliner lacked a gel cushion for pressure relief, despite care plan instructions. Staff interviews revealed confusion about the frequency of dressing changes and the absence of necessary pressure-relieving equipment. The deficiencies in wound care and documentation for both residents highlight a failure to adhere to physician orders and care plans, resulting in inadequate pressure ulcer management. The lack of consistent documentation and appropriate interventions, such as offloading and pressure relief, contributed to the worsening of the residents' conditions. Staff interviews further indicated a lack of clarity and understanding regarding wound care protocols and responsibilities.
Staffing Shortages Lead to Delayed Care and Inadequate Personal Care
Penalty
Summary
The facility failed to ensure timely response to call lights and adequate personal care for residents, leading to significant dissatisfaction and discomfort among the residents. Multiple residents reported long wait times for call lights to be answered, with some waiting up to an hour and forty-five minutes. This delay in response left residents feeling neglected, unsafe, and in some cases, physically uncomfortable due to unmet needs such as assistance with toileting and transfers. The lack of timely response was attributed to insufficient staffing, with reports of only one CNA available for a large number of residents requiring mechanical lift transfers. In addition to the call light issues, the facility also failed to provide regular bathing and personal care for several residents. Residents reported having received only one bath since their admission, leading to feelings of uncleanliness and discomfort. The lack of adequate personal care was further exacerbated by staffing shortages, with staff members acknowledging that they were unable to complete all necessary tasks, including bathing and dressing changes, due to the high acuity of residents and insufficient staffing levels. Staff interviews revealed a high turnover rate in nursing management positions, contributing to the ongoing staffing challenges. The facility relied on temporary staff to fill gaps, which affected the consistency and quality of care provided. Staff members expressed frustration over the inability to meet residents' needs and the impact of staffing shortages on their ability to perform their duties effectively. The report highlights the facility's struggle to maintain adequate staffing levels and the resulting negative impact on resident care and satisfaction.
Improper Medication Labeling and Disposal
Penalty
Summary
The facility failed to ensure proper labeling and disposal of medications and medical supplies, which could negatively affect residents receiving expired medications or supplies. During observations, it was found that multiple vials of Tubersol intradermal injection solution were opened but not dated, and various medical supplies, including needles, blood collection tubes, and COVID test kits, were expired yet still available for use. Staff members were unclear about their responsibilities for monitoring and discarding expired items, indicating a lack of consistent oversight and management. Additionally, insulin pens and other medications were found opened and undated across different units, including Rimview and Copper Crest. Staff interviews revealed that there was an understanding that medications should be dated when opened, but this practice was not consistently followed. The lack of proper dating and disposal of medications and supplies suggests a systemic issue within the facility's medication management processes, potentially compromising resident safety.
Deficient QAPI System and Staffing Issues
Penalty
Summary
The facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) system to address performance improvement issues related to staffing, resident showers, and infection control. The QAPI plan provided by the facility was incomplete and lacked a documented process for maintaining identified concerns at acceptable levels of performance. The plan did not describe how the facility conducts required QAPI and Quality Assurance and Assessment (QAA) committee functions for identifying and correcting quality of care and quality of life deficiencies. The facility's QAPI documents were undated and only included slides with general goals, without specific processes or time frames for tracking and improving concerns. Interviews with staff revealed significant turnover in nursing management positions, which affected the facility's ability to manage staffing needs and training. The facility was in the process of hiring its sixth Director of Nursing (DON) within a year, leading to inconsistent management of nurse staffing issues. Additionally, the facility's infection control measures were not up to date due to the turnover of Assistant Directors of Nursing (ADONs) and DONs. The QAPI committee's efforts to address issues, such as a skin action plan related to showers, were disrupted by staff turnover, leading to incomplete implementation of corrective actions.
Failure to Implement Care Plans for Pressure Ulcer Prevention and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to the care plan for a resident by not placing a gel cushion on the recliner for pressure ulcer prevention. The resident, who had a history of sleeping in a recliner for fifteen to twenty years, developed a pressure ulcer on her buttocks. Despite the care plan indicating the need for a gel cushion, observations on multiple occasions revealed the absence of the cushion in the recliner. Interviews with staff confirmed the necessity of the gel cushion, yet it was not implemented, leading to the deficiency. Additionally, the facility did not update the care plan for another resident requiring enhanced barrier precautions due to the presence of an indwelling catheter for dialysis. The resident's care plan lacked interventions for enhanced barrier precautions, which are necessary for residents with wounds or indwelling medical devices. Staff acknowledged the oversight and were conducting an audit to ensure all applicable residents had the necessary precautions listed in their care plans.
Failure to Provide Dental Services for Residents
Penalty
Summary
The facility failed to provide necessary dental services for three residents, leading to discomfort and embarrassment for the individuals involved. Resident #36 expressed embarrassment and discomfort due to a missing upper right tooth and a left lower tooth that required a crown. Despite these issues, the resident's Minimum Data Set (MDS) did not reflect any broken or loosely fitting dentures or mouth pain. Resident #11 reported that her dentures did not fit correctly, causing discomfort and leading her to stop wearing them. This resident also experienced a weight loss of 3.82% over three months, which could be related to her dental issues. Resident #66 also reported that her dentures did not fit properly, making it difficult for her to chew. Despite these complaints, there were no dental appointments, notes, or referrals found for any of the three residents. Staff member A confirmed the absence of any dental service documentation for these residents, indicating a lack of follow-up on their dental needs.
Failure to Follow Physician-Ordered Therapeutic Diets
Penalty
Summary
The facility failed to ensure that physician-ordered therapeutic diets were followed for several residents. Resident #11, who was on a renal diet due to End Stage Renal Disease, reported being served tomatoes and high sugar foods, which are not suitable for her condition. Resident #15 mentioned that the diet served varied depending on the cook on duty. Resident #7, a diabetic, was served a breakfast high in carbohydrates, including oatmeal with brown sugar and a bagel, despite her meal ticket indicating a Carbohydrate Controlled (CCHO) diet. Similarly, residents #39, #36, and #66, all on CCHO diets, were served meals that included high carbohydrate items like hot dogs, french fries, and jello desserts. Resident #10, who required a No Added Salt (NAS) diet due to water retention issues, reported being served salty foods. Staff member M admitted to being unsure about the specifics of therapeutic diets such as CCHO and renal diets, and stated that the last training on therapeutic diets was six to eight months ago. Staff member K confirmed that therapeutic diets were not being followed, providing an example of diabetics being served regular syrup. These findings indicate a systemic issue in the facility's adherence to prescribed dietary requirements for residents.
Inconsistent Implementation of Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure consistent implementation of enhanced barrier precautions (EBPs) for several residents, leading to potential infection control issues. Resident #63, who had a below-the-knee amputation with open incision areas, reported that nurses only wore gloves during dressing changes, contrary to the facility's policy requiring gowns and gloves. An observation confirmed that a staff member did not follow proper PPE protocol during wound care, failing to sanitize hands and don gloves appropriately. Similarly, Resident #346, with dressings from a double amputation, noted that staff did not use the PPE provided in his room, and interviews with staff revealed a lack of adherence to EBP protocols. Additionally, residents #5 and #6, who required catheter care, reported inconsistent use of gowns by staff, with gloves being the primary protective measure used. The facility's policy, which mandates gown and glove use for wound care and high-contact activities, was not consistently followed. Interviews with staff indicated a lack of understanding and training regarding when and how to implement EBPs, with some staff unaware of the requirements or not having practiced donning and doffing PPE. This lack of consistent education and adherence to infection control protocols increased the risk of negative outcomes for the facility's population.
Failure to Properly Manage Self-Administration of Medications
Penalty
Summary
The facility failed to appropriately manage medications for a resident who was self-administering drugs. During an observation, it was noted that the resident had eight pills in a medication cup at her bedside, along with inhalers. The resident reported that staff would leave her medications in her room early in the morning. A review of the resident's Medication Administration Record (MAR) indicated that several medications, including a controlled substance, were administered to her that morning. However, the resident's Self Administration of Medication Evaluation only authorized her to self-administer inhalers, not other medications. Interviews with staff revealed a lack of understanding and adherence to the facility's policies regarding medication administration and self-administration. Staff members acknowledged that leaving medications, especially a narcotic, at the bedside was unacceptable. Despite this, there was no staff education on resident self-administration of medications. The facility's policy on controlled substances stated that only authorized personnel should have access to Schedule II drugs, yet this was not followed. The facility's policy on self-administration required medications to be stored securely, which was not the case for this resident.
Failure to Develop Comprehensive Baseline Care Plan
Penalty
Summary
The facility failed to develop and implement a baseline care plan that addressed the immediate care needs of a resident who was admitted after being hospitalized with pneumonia. The resident, who was transferred to the long-term care facility to regain strength and continue living independently, began physical therapy shortly after admission. However, the baseline care plan, created by the admitting nurse and intended to be updated by the interdisciplinary team, did not include necessary instructions for respiratory support and rehabilitation therapy services. This omission was identified during a review of the resident's electronic medical record and the facility's policy on baseline care plans, which mandates the inclusion of physician orders and therapy services to ensure effective, person-centered care.
Inadequate Bathing and Repositioning Care for Residents
Penalty
Summary
The facility staff failed to provide adequate bathing and repositioning care for two residents, leading to deficiencies in personal hygiene and skin care. Resident #346, who was dependent on staff for bathing and repositioning due to surgical wounds and skin breakdown, reported receiving only one shower since admission and no bed baths. Observations confirmed the resident's hair was oily and matted, and the resident expressed discomfort and dissatisfaction with the lack of personal cleanliness. Staff interviews revealed time constraints and workload issues, preventing them from completing all necessary tasks, including regular bathing and repositioning. Resident #347 also experienced inadequate bathing care, having received only one shower since admission despite a preference for showers every two days. The resident attempted self-cleaning but was discouraged from doing so by staff. Both residents' medical records indicated a preference for routine bathing, but their care plans lacked specific details on bathing preferences and frequency. The facility's failure to adhere to these preferences and provide necessary care contributed to the residents' dissatisfaction and potential health risks related to personal hygiene and skin integrity.
Failure to Change PICC Line Dressing as Ordered
Penalty
Summary
The facility nursing staff failed to provide appropriate treatment for a resident with a PICC line, as per physician orders. During observations, it was noted that the resident's PICC line bandage was improperly positioned and had not been changed according to the schedule. A staff member admitted to using gauze to stabilize the bandage, indicating that the dressing had not been changed by the staff. The resident's physician orders required the PICC line dressing to be changed every Monday during the day shift, but there was no documentation of dressing changes on the specified dates. The situation escalated when the resident's PICC line was pulled out, necessitating a visit to the Emergency Department where the line was removed and replaced with an IV port. The resident reported that the new IV port was stuck to his pajamas the following morning. Staff interviews revealed that they felt overwhelmed and unable to complete all expected tasks, which contributed to the oversight in care. The facility's guidelines for IV dressing changes emphasize the importance of maintaining sterile dressings and changing them if compromised, which was not adhered to in this case.
Failure to Provide Nebulizer Treatment for Resident with Respiratory Concerns
Penalty
Summary
The facility failed to provide necessary respiratory care for a resident with acute respiratory failure and intermittent acute airway obstruction. The resident, who had been receiving nebulizer treatments every four hours at home, expressed concerns about worsening breathing and the absence of nebulizer treatments since admission. Observations confirmed the lack of a nebulizer machine in the resident's room. Despite having a physician's order for nebulizer treatments documented in the Medication Administration Record (MAR), staff confirmed that no treatments had been administered, nor was there any documentation of the treatments being offered or refused in the resident's Electronic Health Record (EHR).
Inadequate Monthly Medication Review for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a licensed pharmacist adequately addressed and documented the monthly medication regimen review for a resident who was receiving four psychotropic medications. The resident's medication administration record for January 2025 showed prescriptions for Olanzapine, Clonazepam, Trazodone, and Paroxetine, with the Olanzapine lacking an appropriate diagnosis. Despite requests made in July and October 2024 to obtain an appropriate diagnosis for Olanzapine and to consider gradual dose reduction (GDR) for the medications, no dose reductions were attempted, and the diagnosis for Olanzapine remained unchanged. During an interview, staff members acknowledged the pharmacy's failure to track psychotropic medications and follow up on recommendations, indicating that the pharmacy did not thoroughly review the medical record to make appropriate suggestions for the monthly drug regimen review.
Failure to Implement Gradual Dose Reductions for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that gradual dose reductions (GDR) were implemented or documented as clinically contraindicated for residents receiving psychotropic medications. This deficiency was identified for three residents. For one resident, the care plan highlighted the need for GDR due to potential adverse effects of antipsychotics, yet no GDR was attempted or documented as contraindicated. The resident's medication administration record showed multiple psychotropic medications, but the pharmacist's progress note did not address changes made by the psychiatric provider. Another resident's medication administration record showed ongoing psychotropic medication use without GDR attempts, despite a history of failed GDRs and instructions for GDR to come from psychiatry. The third resident had been on several psychotropic medications for over seven months without any dose reductions attempted, and the pharmacy review failed to make appropriate recommendations. Interviews with staff revealed that the facility was aware of issues with the pharmacy's failure to track psychotropic medications and follow up on recommendations. The facility's policy required GDR attempts within the first year of a resident being on psychotropic medication unless clinically contraindicated, but this was not adhered to. Staff members acknowledged that the pharmacy did not thoroughly review medical records to make appropriate suggestions during monthly drug regimen reviews, contributing to the deficiency.
Deficiency in Tracking and Administering Pneumococcal Vaccines
Penalty
Summary
The facility failed to ensure that resident immunizations were up to date according to CDC recommendations for three of the forty sampled residents. Resident #10's electronic health record (EHR) indicated that they had received two pneumococcal vaccines, the Pneumococcal Polysaccharide Vaccine (PPSV23) and the Pneumococcal Conjugate Vaccine (PCV13), but an additional vaccine (PCV20 or PCV21) was recommended. Resident #336's EHR showed no pneumococcal vaccines were administered, although a facility document indicated a refusal with the comment 'up to date.' Similarly, resident #32's EHR showed no pneumococcal vaccines were administered, with a refusal noted in the facility document. Interviews with staff revealed inconsistencies and a lack of clarity in the process of tracking and inputting immunizations. Staff member B and N acknowledged that immunizations were tracked upon admission, but staff member O, who was responsible for tracking, admitted to having no clinical background and relied on residents' statements regarding their vaccination status. Staff member O also expressed uncertainty about whether a nurse had oversight of the immunization process, indicating a potential for missed immunizations. The facility's policy on pneumococcal vaccines, revised in March 2022, stated that residents should be assessed for vaccine eligibility prior to or upon admission, but the current practice did not align with this policy, leading to the identified deficiencies.
Delayed Initiation of Hospital Discharge Medications
Penalty
Summary
The facility failed to ensure that nursing staff transcribed and initiated physician orders for prescribed medications in a timely manner for a resident who returned from the hospital. The resident, who had been hospitalized for bronchitis, reported that the medications prescribed upon discharge were not started until a day or so after her return to the facility. Interviews with staff revealed that there was a delay in entering the physician discharge orders, which were not entered until several days after the resident's discharge from the hospital. This resulted in a five-day delay in starting the prescribed medications, including dexamethasone and doxycycline. The facility's process for handling new medication orders was found to be lacking, with staff indicating that there was no clear system in place for checking on new orders or ensuring they were received and initiated. The assistant director of nursing was previously responsible for reviewing discharge paperwork and clarifying medication orders with the pharmacy, but inconsistencies in nurse staffing and management turnover contributed to the issue. The facility's policy required nursing staff to communicate prescriber orders to the pharmacy and ensure timely administration of medications, but this was not effectively implemented, leading to the deficiency.
Failure to Provide Scheduled Bathing and Grooming for Dependent Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for dependent residents, specifically in the areas of bathing and grooming. Resident #7 reported not having received a shower for over four weeks, despite being scheduled for showers twice a week. The resident's ADL/Bathing record confirmed significant gaps between showers, with 47 days and 29 days without a shower on two separate occasions. Resident #7 expressed that staff were often too busy to provide the scheduled showers. Similarly, resident #5 had not received a shower in weeks and was highly dependent on staff for hygiene care due to upper and lower extremity limitations. The resident's records showed a 25-day gap without a shower. Resident #4 also experienced long periods without bathing, with 44 and 34 days between showers. This resident expressed feeling unclean and attributed the lack of showers to staff being busy. Staff member E confirmed that while most scheduled showers were completed, some were occasionally missed due to workload, as she was responsible for 15 residents during her shift.
Failure to Supervise Resident with Dementia at Medical Appointment
Penalty
Summary
The facility failed to provide adequate supervision for a resident with a dementia diagnosis, resulting in the resident being left unattended at a medical clinic. The resident, identified as having severe cognitive impairment with a Brief Interview for Mental Status score of five, was transported to an outside medical appointment by a facility employee. The resident's care plan indicated a risk for wandering and exit-seeking behaviors due to unspecified dementia and cognitive impairments. Despite these documented risks, the resident was left unsupervised at the medical office, as confirmed by interviews with facility staff. One staff member acknowledged that a staff member should have stayed with the resident due to their severe cognitive impairment, while another staff member stated that their role did not include staying with residents during appointments.
Inappropriate Catheter Use and Delayed Provider Notification
Penalty
Summary
The facility failed to provide necessary catheter supplies for a resident, leading to the use of inappropriate materials that caused an allergic reaction. A resident with a known allergy to silicone catheters experienced a rash after a suprapubic catheter replacement. The resident's medical record documented an allergy to silicone foley catheters, with a moderate severity reaction of blisters. Despite this, a silicone catheter was used on the resident when the suprapubic catheter became clogged and could not be flushed. The nurse who replaced the catheter was unaware of the resident's allergy and assumed silicone was hypoallergenic, leading to the use of the available silicone catheter. The facility also failed to notify the medical provider in a timely manner after the inappropriate catheter was inserted. The nurse did not contact the medical provider's office immediately after the catheter change but instead relayed the information to the incoming nurse during the shift report. The resident developed a rash, possibly related to the silicone catheter, and a new order was received for a catheter change and medication to address the allergic reaction. The delay in notifying the medical provider and the use of inappropriate catheter supplies contributed to the deficiency in care for the resident.
Failure to Maintain Sanitary Food Service and Hand Hygiene
Penalty
Summary
The facility failed to ensure food was served in a sanitary manner and did not practice proper hand hygiene while serving meals between residents. During an observation, a half-eaten grilled cheese sandwich belonging to a staff member was found on the resident tray line, and another staff member was seen drinking a personal drink in the tray line area while preparing resident dinner trays. Additionally, a staff member was observed serving trays to residents in their rooms without performing hand hygiene between each meal delivery. The staff member admitted to not knowing the requirement for hand hygiene between serving trays to residents. Interviews with staff members revealed that training had been provided on not eating or drinking while working the tray line and on hand hygiene when delivering and assisting residents with meals. The facility's policy on hand hygiene, revised in August 2019, mandates the use of an alcohol-based hand rub or soap and water before and after eating or handling food, and before and after assisting a resident with meals. Despite this policy and the training provided, the observed practices did not align with the facility's standards, leading to the identified deficiencies.
Failure to Assist Resident with Meals
Penalty
Summary
The facility failed to provide assistance with meals for a resident identified with weight loss. During multiple observations on 5/19/24, a meal tray was delivered to the resident and placed on her bedside table while she was asleep. No attempt was made by the staff to rouse the resident or assist her with the meal. The meal tray remained untouched for over an hour, and the staff collecting the trays did not notice or address the untouched meal. Interviews with staff revealed that the resident required assistance with meals and should be in the dining room for cueing, but the agency staff were unaware of these needs and did not have access to the resident's dietary information in the electronic medical record. Record reviews showed that the resident had been triggering for weight loss and required more cueing to focus on eating meals. The resident's care plan indicated the need for meal setup and assistance with eating, as well as supervision during meals to encourage intake. Despite these documented needs, the resident did not receive the necessary assistance, leading to the deficiency observed by the surveyors.
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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