St John's Lutheran Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Billings, Montana.
- Location
- 3940 Rimrock Rd, Billings, Montana 59102
- CMS Provider Number
- 275024
- Inspections on file
- 23
- Latest survey
- July 22, 2025
- Citations (last 12 mo.)
- 23
Citation history
Health deficiencies cited at St John's Lutheran Home during CMS and state inspections, most recent first.
Surveyors found that expired food items were not discarded, and perishable foods were not properly labeled or dated in several areas of the facility. Dietary staff did not have or follow written policies for food storage and handling, and dish sanitization water was not tested due to a lack of test strips, despite policy requirements for safe food handling and sanitation.
Staff did not consistently perform hand hygiene after assisting residents or while preparing and serving food, including serving coffee and feeding multiple residents without washing hands between contacts. Enhanced barrier precautions were not implemented for a resident with a chronic wound, as staff provided care without required PPE. Additionally, a staff member failed to follow glove use protocols during food preparation, using the same glove for multiple tasks and handling both food and soiled items.
The facility did not report findings of a resident-to-resident verbal altercation to the State Survey Agency within the required timeframe, and also failed to report allegations of resident-to-resident physical abuse within 24 hours as required by policy. Delays were attributed to unclear staff responsibilities and incidents occurring over a weekend, resulting in late notifications and documentation.
The facility did not make grievance forms readily available in common areas, failed to provide a secure method for anonymous written grievance submission, and did not ensure residents were informed about how to file grievances anonymously. A resident was unaware of the process, and staff confirmed forms were only available in an office, not accessible to residents.
A resident receiving oxygen therapy via nasal cannula at 2 L/min, as ordered by a medical provider, did not have this treatment included in their care plan. Staff confirmed the omission and were unsure why the care plan was not updated to reflect the resident's oxygen needs.
The facility did not update care plans to reflect the specific activity preferences and participation of two residents, nor did it include enhanced barrier precautions for a resident with an indwelling urinary catheter. Staff interviews and record reviews showed that individualized interventions and infection control measures were missing from the care plans, despite observations of resident needs and facility policy requirements.
Two residents experienced medication errors when staff delayed insulin administration until after a meal and incorrectly documented and omitted a scheduled dose of pantoprazole, resulting in a medication error rate above five percent.
The facility failed to meet residents' nutritional needs and follow planned menus. Staff did not review diet orders or menus, served meals not on the menu, and used improper serving methods. Inadequate meal preparation led to insufficient portions and lack of appropriate substitutes.
The facility failed to update care plans for three residents, leading to deficiencies in addressing their current needs. A resident dealing with grief lacked interventions for coping, another with frequent falls did not have a care plan including a camera for fall prevention, and a third resident's care plan was outdated, not reflecting a recent move. Staff acknowledged the need for timely updates.
The facility did not post daily nurse staffing information in four cottages housing 51 LTC residents. During a survey, it was observed that no postings were present. Interviews with staff revealed a lack of awareness about the absence of postings in the cottages, although staffing was posted on the rehabilitation unit.
The dietary department failed to provide residents with a nourishing diet and did not adhere to therapeutic diet requirements, leading to potential negative nutritional outcomes. Staff members did not review diet orders, resulting in improper serving sizes and failure to follow dietary guidelines. Interviews revealed a lack of awareness and adherence to dietary protocols, with staff failing to consult residents about meal preferences and not ensuring consistent nutrition.
The facility failed to provide sufficient and competent staff in food services, leading to delayed meal service and inadequate dietary management. Cooks were shared between cottages, causing meal delays, and staff lacked training on dietary changes and resident allergies. Observations showed understaffing led to missed cleaning duties and improper meal preparation, increasing risks for residents.
The facility failed to accommodate resident dietary needs in the [NAME] Cottage, as staff did not review diet orders or menus, leading to inappropriate meal service. Staff were unaware of special diets, and residents were not asked about meal preferences. Observations showed non-compliance with textural modifications, such as unminced sausage for residents on a minced and moist diet.
The facility's kitchens in the Powers, [NAME], and [NAME] Cottages were found to have significant sanitation issues, including dirty floors, improperly labeled and stored food, and poor hand hygiene practices by staff. Observations revealed black film on kitchen floors, leaking freezers, and sticky cupboard doors. Staff members were seen using contaminated gloves to handle food, and interviews highlighted concerns about cleanliness and a shortage of cooks affecting cleaning routines.
The facility failed to maintain proper infection control and PPE use during a COVID-19 outbreak. Staff were observed mishandling clean and dirty linens, improperly washing hands, and being unaware of outbreak status due to missing signage. A staff member was seen without a mask in an outbreak area.
A facility failed to assess two residents' ability to self-administer medications before leaving them unattended. A staff member left medications on a table and exited the dining area to take a phone call, without ensuring the residents had been assessed or had a physician's order for self-administration. Interviews confirmed the requirement for such assessments and orders, but reviews of the residents' records showed these were not in place.
A facility failed to accurately complete a resident's Quarterly MDS assessment. A staff member noted the resident often refused showers and personal care, and during one instance, observed redness in the resident's groin. Despite the nurse's recommendation for treatment, the resident refused care. The MDS assessment did not document these refusals, and the staff member responsible for the assessment could not explain the omission.
The facility failed to create timely baseline care plans for two residents. One resident, admitted for end-of-life care, had no care plan completed before passing away. Another resident with complex medical needs had a delayed and incomplete care plan, missing critical information on ADL assistance, seizure precautions, and speech therapy. Facility policy requires baseline care plans within 48 hours of admission.
A facility failed to consistently assess and document a resident's skin condition as part of preventative care. A staff member noticed redness in a resident's perineum during a shower and informed a nurse, who suggested treatment options that the resident refused. A review of records showed a lack of routine skin assessments, despite the facility's policy requiring weekly assessments.
A resident experienced repeated falls resulting in back injuries, and the facility failed to identify root causes or evaluate interventions. Despite frequent checks and camera monitoring, the care plan did not address falls individually or update interventions. The resident was removed from the Fall Management Program, and no new strategies were implemented, contrary to facility policy.
A resident dealing with grief and confusion after the loss of a spouse did not receive timely mental health services. Despite expressing feelings of missing his wife, the resident's care plan lacked interventions for grief or loneliness. Although a staff member provided some emotional support, there were no documented social services notes or evidence of grief counseling. Behavioral health counseling was ordered only after the resident's son reported forgetfulness.
The facility failed to limit PRN psychotropic medications to 14 days or document rationale for extended use for two residents. One resident continued using clonazepam PRN for insomnia without a stop date, despite a pharmacist's recommendation for adjustment. Another resident had lorazepam PRN for anxiety without a stop date, and the provider declined discontinuation despite no use in 30 days. A staff member noted awareness of the 14-day limit, but one physician did not always follow the policy.
A facility failed to obtain a signed consent for a pneumococcal vaccine for a resident who was confused and unable to consent. A staff member noted that the nurse should have contacted the resident's legal representative to discuss the vaccine's risks and benefits and to obtain consent. The facility's policy requires determining immunization status upon admission and offering vaccination to those without documentation, with vaccine type based on age and previous immunizations.
A facility failed to report an allegation of resident neglect within the required 24-hour timeframe. The incident occurred over a two-day period and was communicated to staff via email, but the report to the State Survey Agency was delayed. Staff member B acknowledged the delay, citing a lack of timely information despite being aware of the reporting requirements.
A resident's morning insulin was administered three hours late due to a delay in returning to their room after breakfast. The insulin, scheduled for 7:00 a.m., was given at 10:11 a.m. without re-checking the resident's blood sugar or notifying the physician about the delay.
Expired Food and Inadequate Sanitation Practices Identified
Penalty
Summary
Surveyors observed that the facility failed to dispose of expired food items and did not ensure proper labeling and dating of perishable foods in multiple cottages and the main storage room. Several food items, including coffee creamers, sliced cheese, ham, milk, prune juice cups, grape juice, chips, and fig newtons, were found to be expired or lacked open dates. Staff confirmed that expired items should be discarded and that all items should be dated, but these practices were not consistently followed. Additionally, staff reported the absence of dietary policies for food storage and handling, relying only on verbal instructions to follow Serve Safe guidance. Further observations revealed that dietary staff did not test the sanitizer water used for dishwashing, as there were no test strips available in any of the cottages. Staff stated that Ecolab managed the sanitizer units and checked them monthly, but no in-house testing was performed. Review of the facility's food safety policy indicated requirements for proper food handling, labeling, and dating, as well as the use of leftovers within three days, but these procedures were not being implemented as outlined.
Failure to Follow Hand Hygiene, Glove Use, and Enhanced Barrier Precautions
Penalty
Summary
Staff failed to perform appropriate hand hygiene after assisting residents and while preparing and serving food. Observations included a staff member assisting a resident to a dining table, touching the resident, and then serving coffee to multiple residents without performing hand hygiene between contacts. Another staff member was seen feeding two residents alternately without any hand hygiene during the meal, and a third staff member assisted three residents with their meals after moving a stool with bare hands, again without performing hand hygiene. The facility also failed to implement enhanced barrier precautions (EBP) for a resident with a chronic wound. The resident was observed with a wound dressing on her left foot, and staff assisted her with transfers and personal care without wearing an isolation gown, despite facility policy requiring EBP for residents with chronic wounds during high-contact care activities. Interviews revealed confusion among staff regarding which residents required EBP and when to use personal protective equipment (PPE). Additionally, staff did not follow proper glove use and hand hygiene protocols during food preparation. One staff member was observed wearing a glove on one hand while cooking, then using the same gloved hand to handle ready-to-eat food, touch various surfaces, and handle soiled items before removing the glove. Facility policies required hand washing before donning gloves, changing gloves as often as hands need to be washed, and not using the same gloves for multiple tasks, but these procedures were not followed.
Failure to Timely Report Abuse Allegations and Investigation Findings
Penalty
Summary
The facility failed to report the findings of a facility-reported incident to the State Survey Agency within the required timeframe for two residents involved in a verbal altercation. The incident occurred in a cottage dining room, where one resident was witnessed yelling at and insulting another. Although both residents were evaluated by staff and one was assessed for behavioral health treatment, the facility did not submit the investigation findings to the State Survey Agency until two days after the required deadline. Interviews with staff revealed confusion and lack of clear assignment regarding who was responsible for submitting follow-up reports, contributing to the delay. Additionally, the facility did not report allegations of resident-to-resident abuse to the State Survey Agency within 24 hours for another incident involving a physical altercation between two residents, resulting in a visible injury. The delay occurred because the incident happened on a weekend, and the responsible staff member did not review or report the event until the following Monday. The facility's own policy requires notification to the State Survey Agency within 24 hours and submission of investigation documentation within five business days, which was not followed in these cases.
Failure to Provide Anonymous Grievance Submission Process and Readily Available Forms
Penalty
Summary
The facility failed to develop and implement a policy and procedure that allowed residents to submit written grievances anonymously, did not provide residents with readily available grievance forms, and did not offer a secure receptacle for anonymous grievance submission. During an observation, no documentation was found in the common areas regarding how residents could file a grievance, and no grievance forms or secure submission boxes were present. Staff interviews confirmed that grievance forms were kept in a staff office and not accessible to residents in the common areas, and that there was no secure method for anonymous submission. A resident interviewed was unaware of the location of grievance forms or the process for submitting an anonymous grievance, stating she would typically inform staff of any issues. Review of the facility's grievance policy indicated that forms should be available adjacent to the Resident Rights posting and that grievances could be submitted anonymously via a compliance hotline, but these procedures were not observed in practice during the survey.
Failure to Include Oxygen Therapy in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident who required oxygen therapy. Observation revealed the resident was using a nasal cannula with an oxygen concentrator set at 2 liters per minute, as ordered by the medical provider. However, review of the resident's current care plan showed no focus, goal, or interventions related to oxygen therapy. During an interview, a staff member confirmed that the care plan had not been updated to include the resident's oxygen therapy, and was unsure why this omission occurred. The deficiency was identified through observation, interview, and record review, which confirmed that the resident's care plan did not address the ordered oxygen therapy, despite the resident actively receiving this treatment.
Failure to Update Care Plans for Activities and Infection Control
Penalty
Summary
The facility failed to ensure that care plans were updated to reflect resident-centered activity preferences and infection control measures for sampled residents. For one resident, observations and interviews revealed that although she participated in some activities, such as church services and family visits, her care plan did not document her specific preferences, the importance of church, or her limited participation in group activities. Staff interviews confirmed that changes in activity participation were not consistently documented in the care plan, and the care plan lacked individualized interventions such as one-to-one visits. Another resident, who was hard of hearing and rarely participated in group activities, also had a care plan that did not reflect her interests or preferences. Despite being dependent on staff for social needs and having recently moved cottages, her activity assessment was incomplete, and care team meeting notes were left blank regarding activities. The care plan failed to include her enjoyment of family visits and music or the use of one-to-one visits to address her needs. Additionally, a resident with an indwelling urinary catheter had enhanced barrier precaution signage on her door, but there was no personal protective equipment available for staff, and her care plan did not include interventions for enhanced barrier precautions. Staff interviews indicated that care plans were not updated to include these precautions, despite facility policy requiring such updates for residents with indwelling medical devices. The care plan only addressed the presence of the catheter and related self-care deficits, omitting necessary infection control interventions.
Medication Error Rate Exceeds Five Percent Due to Administration and Documentation Errors
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by a calculated error rate of 5.41 percent during the survey period. One incident involved a staff member delaying the administration of insulin to a resident until after the resident had finished breakfast, despite a physician's order specifying that insulin should be given before meals. In another case, a staff member administered acetaminophen to a resident during breakfast but incorrectly documented it as pantoprazole in the medication administration record (MAR), and did not administer the pantoprazole as scheduled before the resident ate, contrary to the physician's order for administration at 7:00 a.m. These actions resulted in medication errors for two residents out of a sample of twenty-five.
Failure to Meet Nutritional Needs and Follow Menus
Penalty
Summary
The facility failed to ensure that meals served to residents met their nutritional needs and that staff adhered to the planned menu or offered appropriate substitutes. During observations, staff members did not review residents' diet orders or the menu prior to meal service. Staff member N served bacon using her hands instead of the required scoop size and did not follow the menu, serving regular toast or pancakes instead of the planned banana french toast. Additionally, residents were not asked for their meal preferences. On another occasion, staff member P did not follow the menu and served plain scrambled eggs instead of the planned confetti eggs, cereal, hashbrowns, and toast. The cook ran out of hashbrowns, and no substitute was offered. Further observations revealed that staff member R did not have enough pancakes for all residents and failed to provide a minced meat substitute for breakfast, as required. Instead, she planned to provide double portions of meat at lunch. Eggs sterling was on the menu, but plain scrambled eggs were served, and there were not enough eggs for all plates. Staff member R redistributed eggs from already dished plates to ensure all residents received some, indicating a lack of preparation and adherence to dietary requirements.
Failure to Update Comprehensive Care Plans
Penalty
Summary
The facility failed to update the comprehensive care plans for three residents, leading to deficiencies in addressing their current needs. Resident #41, who was dealing with grief after the death of his wife, did not have a care plan that included interventions for coping with grief, despite staff awareness of his situation. Staff member G admitted to not updating the care plan, acknowledging a lack of diligence in this area. Resident #47, who experienced frequent falls and back pain, did not have a care plan that included the use of a camera for fall prevention, an intervention mentioned by staff member F. Staff member I emphasized the collective responsibility to ensure timely updates to care plans. Additionally, resident #3's care plan was outdated, still reflecting adjustment issues related to a move that occurred over a year ago. The care plan had not been revised to address a more recent move, which could have contributed to the resident's resistance to showers and incontinence care. Staff member C noted the resident's resistance might be due to being new to the cottage, indicating a need for updated care planning to reflect the resident's current situation.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post daily nurse staffing information in the four cottages housing 51 long-term care residents. This deficiency was identified during a survey conducted from August 12 to August 15, 2024. Observations during the survey revealed that no nurse staffing postings were present in any of the cottages. During an interview on August 14, 2024, at 8:17 a.m., a staff member was unable to identify where the nurse staffing information was posted in two of the cottages, although they mentioned that staffing was posted on the rehabilitation unit. Another staff member interviewed on August 15, 2024, at 11:55 a.m., was unaware that there were no staff postings in the cottages.
Dietary Department Fails to Meet Residents' Nutritional Needs
Penalty
Summary
The dietary department failed to provide residents with a nourishing diet and did not adhere to therapeutic diet requirements, leading to potential negative nutritional or health outcomes. Observations revealed that staff members did not review diet orders or therapeutic menus, resulting in improper serving sizes and failure to follow dietary guidelines. For instance, staff member N did not measure portions when serving bacon and used unwashed berries, while staff member P was unaware of special diets and did not ensure uniform serving sizes. Additionally, staff member P ran out of hash browns and did not provide substitutes, and staff member R did not have enough pancakes or eggs to meet the menu requirements. Interviews with staff members indicated a lack of awareness and adherence to dietary protocols. Staff member O admitted to not regularly checking on the cottages and expressed doubt that diets were being followed. Staff members also failed to consult residents about their meal preferences, and there was a general lack of communication and understanding regarding dietary needs. The report highlights multiple instances where dietary staff did not follow established procedures, leading to inconsistent and potentially inadequate nutrition for the residents.
Inadequate Staffing and Competency in Food Services
Penalty
Summary
The facility failed to ensure sufficient staffing with the necessary competencies and skillsets in the food and nutrition services, leading to delayed meal service and inadequate dietary management. During an entrance conference, staff members A and B revealed that cooks were shared between two cottages, resulting in meal preparation and service delays. An observation on 8/14/24 showed that the cook, staff member P, served breakfast 53 minutes late without assistance, contrary to the posted meal time. Staff member P, a CNA not typically involved in cooking, was unaware of dietary changes and resident allergies, indicating a lack of proper training and familiarity with the kitchen operations. Further observations revealed that the facility was understaffed, leading to missed cleaning duties and inadequate meal preparation. On 8/15/24, staff member R was observed with insufficient pancakes and failed to provide a minced meat substitute for breakfast, demonstrating a lack of knowledge about dietary requirements. Breakfast was again served late, highlighting the ongoing staffing and competency issues in the food and nutrition services, which increased the risk of negative outcomes for residents in the affected cottages.
Failure to Accommodate Resident Dietary Needs
Penalty
Summary
The facility failed to provide food that accommodated resident allergies and preferences in the [NAME] Cottage. Observations revealed that staff members did not review resident diet orders or menus prior to meal service. For instance, during a meal service, banana French toast was not served as per the menu, and minced bacon was served with syrup poured on top without considering resident preferences. Additionally, staff members were unaware of the number of special diets required, with one staff member expressing uncertainty about potential allergies to watermelon among residents. Further observations indicated that staff did not adhere to the required textural modifications for residents on specialized diets. For example, sausage was not minced for residents on a minced and moist diet, and no minced meat substitute was provided. Staff members admitted to not having time to prepare the food as required and planned to compensate by providing double portions at a later meal. The lack of adherence to dietary requirements and failure to consult residents about their meal preferences contributed to the deficiency.
Sanitation and Hygiene Deficiencies in Facility Kitchens
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchens of the Powers, [NAME], and [NAME] Cottages, as observed during a survey. The kitchen floors had a heavy accumulation of black film along the edges, and there was water leaking from a freezer door with a towel placed on the floor to absorb it. The freezer had a buildup of ice and rust-colored stains, and there were unlabeled and undated food items in both the freezer and refrigerator. The pantry refrigerator was dirty, with brown smears, red debris, and cheese-like shreds. Additionally, the cupboard doors were sticky, and there was no sanitizing solution for kitchen towels. The handles of the refrigerators and oven were soiled, and several spice containers were left open. Staff members were observed practicing poor hand hygiene and glove use. Staff member P was seen touching her hair and sticky cupboards with gloved hands and then handling food without changing gloves. She also used contaminated gloves to scoop food and handle resident plates. Staff member N similarly used the same pair of gloves to open cupboards, handle food, and serve residents, without changing gloves or washing hands. These practices were observed during breakfast service, where food items were also found to be improperly labeled and stored. Interviews with staff revealed concerns about sanitation and cleanliness in the kitchen. Staff member Q expressed concerns about the dirty vent cover and sprinkler head, while staff member T noted the vents were dirty and difficult to clean without a ladder. Staff member O, who visited the cottages weekly, was unaware of the freezer issues. The facility was experiencing a shortage of cooks, leading to missed cleaning tasks. The registered dietitian's audits highlighted unresolved issues, including dirty kitchen floors, lack of hand hygiene, and improperly labeled leftovers.
Infection Control and PPE Deficiencies During COVID-19 Outbreak
Penalty
Summary
The facility failed to ensure proper infection control practices and the use of appropriate personal protective equipment (PPE) during a COVID-19 outbreak. Observations revealed that a staff member, NF4, was seen carrying clean towels against her uniform and transporting dirty linens uncovered, placing them on the floor near the washing machine. Another staff member, R, was observed washing her hands but turning off the faucet with wet hands before drying them and proceeding with breakfast service. Additionally, during an interview, it was disclosed that the [NAME] Cottage was in outbreak status due to a positive COVID-19 test by a staff member. However, staff member E was seen changing a lightbulb without wearing a mask and was unaware of the outbreak status due to the absence of signage at the employee entrance. Staff member C acknowledged the lack of outbreak signage and stated she would address it immediately.
Failure to Assess Residents' Ability to Self-Administer Medications
Penalty
Summary
The facility failed to ensure that residents were assessed for their ability to self-administer medications before being left unattended while taking medications. During an observation, a staff member left medications for two residents on a table in the dining room and then left the area to take a phone call, leaving the residents unattended. This action occurred without any other nursing staff present to observe the residents taking their medications. Interviews with staff revealed that there was a requirement for an assessment of the resident's ability to safely self-administer medications and a physician's order permitting self-administration. However, reviews of the electronic health records for the two residents involved showed no such assessments or physician's orders. This oversight indicates a failure to adhere to the necessary protocols for medication administration in the facility.
Failure to Accurately Complete Resident Assessment
Penalty
Summary
The facility failed to accurately complete the Quarterly resident assessment for one of the sampled residents. During an interview, a staff member reported that the resident often refused showers and personal care assistance, opting instead for a sponge bath. On one occasion, while assisting the resident with a shower, the staff member noticed redness in the resident's groin area and notified a nurse, who recommended treatment with nystatin powder or cream. However, the resident refused the recommended treatments. Despite these refusals, the Quarterly MDS assessment did not document any behaviors related to the rejection of care during the assessment period. Another staff member, responsible for the assessment, acknowledged awareness of the resident's regular refusal of care but could not explain why this behavior was not coded in the MDS. This oversight led to the deficiency in accurately completing the resident's assessment.
Failure to Implement Timely Baseline Care Plans
Penalty
Summary
The facility failed to develop and implement a baseline care plan for two residents within the required 48-hour timeframe after admission. For the first resident, who was admitted for a short end-of-life stay, no baseline care plan was created, and the resident passed away six days after admission. Staff acknowledged that the care plan was not completed, possibly due to the resident's short stay. The facility's policy mandates that baseline care plans be initiated within 48 hours of admission by the interdisciplinary team (IDT). For the second resident, who was admitted with multiple complex medical conditions including epilepsy, dysphagia, and a suprapubic catheter, the baseline care plan was initiated late and lacked critical information. The care plan did not address the resident's need for assistance with activities of daily living (ADLs), seizure precautions, or speech therapy, despite these being pertinent to the resident's condition. The facility's policy requires that initial care plans include the primary reason for admission and be completed comprehensively within 21 days.
Failure to Document Routine Skin Assessments
Penalty
Summary
The facility nursing staff failed to consistently assess and document the skin condition of a resident as part of preventative skin care measures. During an interview, a staff member revealed that while assisting a resident with a shower, they noticed redness in the resident's perineum and informed a nurse, who suggested treatment options. However, the resident refused the recommended treatments. A review of the resident's electronic health record from January to August showed a lack of routine skin assessments, with only a few notes regarding the resident's skin condition, including a wound on the chin and the red groin. The facility's Skin at Risk Program indicated that skin assessments should be performed weekly, but documentation did not reflect this practice.
Failure to Address and Prevent Repeated Falls
Penalty
Summary
The facility failed to adequately address and prevent repeated falls for a resident who experienced multiple falls, resulting in back injuries. The resident expressed reluctance to ask for help, which contributed to the falls. Despite the implementation of frequent checks and a camera monitoring system, the facility did not effectively monitor the resident, as evidenced by the lack of staff presence in the nurses' room to observe the camera feed. The resident's care plan, initiated in July 2024, did not identify the root causes of the falls or evaluate the effectiveness of existing interventions. The care plan grouped the falls together without addressing them individually or updating interventions based on specific incidents. Post-fall documentation for several incidents failed to identify specific causes or evaluate the effectiveness of interventions, and no new strategies were implemented to prevent future falls. The resident was removed from the Fall Management Program because the provider deemed the falls unavoidable, and staff did not attempt new interventions. The facility's policy required root cause analysis and intervention for each fall, but this was not followed. The Quality Assurance and Performance Improvement committee was responsible for ensuring high-risk residents were included in the Fall Management Program, but the resident was not reviewed by the fall IDT team.
Failure to Provide Mental Health Services for Grieving Resident
Penalty
Summary
The facility failed to provide necessary mental health services to a resident who was experiencing grief and confusion following the death of his spouse. The resident expressed feelings of missing his wife and confusion, indicating a need for mental health support. Despite the resident's family visiting and a staff member providing some emotional support, the resident's care plan was not updated to include interventions for grief or loneliness. Additionally, there were no documented social services notes or evidence of grief counseling provided to the resident. A staff member mentioned placing an order for behavioral health counseling only after the resident's son reported his father's forgetfulness. The lack of documentation and timely intervention contributed to the deficiency identified by the surveyors.
Failure to Limit PRN Psychotropic Medications to 14 Days
Penalty
Summary
The facility failed to ensure that as-needed (PRN) psychotropic medications were limited to 14 days or had documented rationale for extended use by the physician for two residents. For one resident, a pharmacist recommended alternatives to a sleep aid/antianxiety medication, but the physician ordered clonazepam PRN without a stop date. The resident used the medication almost nightly, and despite a pharmacist's recommendation to adjust the regimen and document the next evaluation timeframe, the resident continued on the medication without further documentation through the survey date. For another resident, lorazepam was ordered PRN for anxiety without a stop date, and the resident received it twice in one month. The pharmacy noted the medication had not been used in 30 days, but the provider declined discontinuation and planned to review it within 60 days. An interview with a staff member revealed that medical providers were aware of the 14-day limit for PRN medications, but one physician did not always adhere to the policy. The facility's policy required PRN orders for psychotropic drugs to be limited to 14 days unless the physician documented a rationale and duration for extended use.
Failure to Obtain Consent for Pneumococcal Vaccine
Penalty
Summary
The facility failed to obtain a signed consent for the administration of a pneumococcal vaccine for one of the sampled residents. The resident in question was confused and unable to consent to the administration of the vaccine. During an interview, a staff member indicated that the nurse should have followed up with the resident's legal representative to educate them on the risks and benefits of the pneumococcal vaccination and to obtain their consent or declination. The facility's policy requires that the pneumococcal immunization status of all residents be determined upon admission and that vaccination be offered to those who cannot provide documentation of previous vaccination status. The policy also states that the type of pneumococcal vaccine should be determined based on the resident's age and previous immunizations, following current CDC recommendations.
Failure to Timely Report Allegation of Resident Neglect
Penalty
Summary
The facility failed to report an allegation of resident neglect within the required 24-hour timeframe. The incident involved a staff member allegedly neglecting a resident, which occurred between July 27 and July 29, 2024. The allegation was communicated to staff members J and K via email on July 30, 2024. However, the initial report to the State Survey Agency was not submitted until August 1, 2024, exceeding the 24-hour reporting requirement. During an interview, staff member B acknowledged the delay, attributing it to not being informed of the allegation in a timely manner, despite being aware of the reporting timelines. The facility's policy mandates that the Department of Public Health and Human Services Certification Bureau be notified within 24 hours of such incidents.
Delayed Insulin Administration
Penalty
Summary
The facility failed to provide medications in a timely manner for one of the sampled residents, resulting in a deficiency. During an observation and interview, a staff member was found administering morning insulin to a resident three hours past the scheduled time. The insulin was supposed to be given at 7:00 a.m., but it was administered at 10:11 a.m. The delay occurred because the nurse waited for the resident to eat before giving the insulin, and the resident did not return to their room until after 10 a.m. Additionally, the resident's blood sugar was not re-checked before administering the insulin, and there was no documentation indicating that the physician was notified about the late administration.
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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