Valley View Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Glasgow, Montana.
- Location
- 1225 Perry Ln, Glasgow, Montana 59230
- CMS Provider Number
- 275091
- Inspections on file
- 20
- Latest survey
- January 29, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Valley View Home during CMS and state inspections, most recent first.
The facility did not maintain a designated full-time DON for an extended period, leaving the position vacant while DON responsibilities were informally divided among the IDT. Emails from the administrator showed that the previous DON had left and that a job posting was created, but there was no documentation that the DON’s duties were specifically reassigned to an RN or multiple RNs during the vacancy. A later email documented the start date of a new DON, confirming a gap of several weeks without a formally designated DON.
A resident with dementia, a trauma history, hallucinations, and longstanding behavioral symptoms such as wandering into other rooms, verbal and physical aggression, and disrobing experienced two separate sexual incidents with male residents. In one event, a male was found in the resident’s room with his hands down her pants while she verbally rejected him; in another, staff found a male without pants lying on top of the fully clothed resident on his bed while she yelled for him to get off. Staff interviews and records showed that, although non-pharmacologic interventions (snacks, showers, one-on-one, aroma therapy, warm towels) and multiple psychotropic medication changes were used, the facility did not develop or document a defined monitoring and supervision program specifying the level, duration, or methods of oversight to address the resident’s wandering, entry into other rooms, and sexually related interactions after these incidents, nor were the sexual encounters incorporated as identified triggers in the care plan.
The facility failed to report a resident-to-resident abuse incident to the State Survey Agency within the required 24-hour timeframe. Staff reported that incidents must be reported within 24 hours, with 2-hour reporting for serious bodily injury and investigation results due within 5 days, and the facility’s written policy reflected these requirements. However, an altercation between two residents was reported more than 24 hours after it occurred, contrary to the facility’s mandatory reporting policy and the timelines described by staff.
The facility failed to screen visitors for COVID-19 symptoms during an outbreak, neglected to post transmission-based precaution signage for COVID-19 positive residents, and did not practice proper hand hygiene during a laundry pass. Additionally, enhanced barrier precautions were not followed for residents with indwelling medical devices, increasing the risk of infection spread.
The facility did not document declinations or provide education on the COVID-19 vaccine for two residents whose representatives refused the vaccine. Staff confirmed the absence of signed declinations and educational documentation, contrary to facility policy requiring such records in the medical file.
A resident at nutritional risk experienced a severe weight loss due to the facility's failure to implement care plan interventions. Observations showed the resident's meals were left untouched, and staff did not provide necessary encouragement or cueing during mealtimes. The resident's weight was not monitored weekly as required by facility policy, contributing to a 9.2% weight loss over three months.
The facility failed to label and date food items in the resident nourishment refrigerator, as observed with an unlabeled Tupperware containing an unknown substance. A staff member indicated that housekeeping was responsible for cleaning these refrigerators and noted that family members often placed items without staff knowledge. The facility's policy required all prepared food to be labeled, dated, and consumed within three days.
A facility failed to ensure a resident received the pneumococcal vaccine series. The resident's immunization record showed they received one vaccine in 2018, but the type was unspecified. Consent for further vaccination was given in 2024, but a staff member admitted to not arranging a vaccination clinic and being behind on immunization reviews. Facility policy required assessment for vaccine eligibility within five days of admission, which was not followed.
A cognitively impaired resident with a history of elopement attempts left a facility unsupervised, reaching a nearby school playground. The resident's care plan included interventions to prevent elopement, but several staff members were unaware of these measures. The facility's elopement book was not easily accessible, and communication about elopement risks was insufficient, contributing to the incident.
Failure to Maintain a Designated Full-Time DON
Penalty
Summary
The facility failed to designate a full-time DON as required, leaving the position vacant for 37 days. During interviews, staff members B and C reported that the facility had been without a DON for a little over a month and that DON tasks were divided among the IDT during this period. An email from staff member A dated 9/8/25 showed an advertisement posting for the DON position and indicated that the IDT took over DON tasks after the previous DON left, but there was no documentation that the prior DON’s duties were specifically reassigned to an RN or multiple RNs. Another email from staff member A on 9/8/25 confirmed that the previous DON no longer worked at the facility, and a subsequent email dated 10/16/25 documented that staff member B started as the new DON on that date, confirming the facility was without a designated DON from 9/8/25 through 10/16/25. No residents or specific patient conditions were mentioned in the report, and the deficiency centers solely on the lack of a designated full-time DON and the absence of documented reassignment of DON responsibilities to an RN during the vacancy period.
Failure to Implement Adequate Supervision and Monitoring After Resident Sexual Incidents
Penalty
Summary
The deficiency involves the facility’s failure to identify and implement necessary and beneficial supervision and monitoring interventions for a cognitively impaired resident with a history of trauma and significant behavioral symptoms, including wandering into other residents’ rooms and sexually related interactions with male residents. Interviews with multiple staff members confirmed that the resident frequently wandered the halls, entered other residents’ rooms, displayed verbal and physical aggression, yelled, ran on the unit, and sometimes removed her clothing or kept her hands in her pants. Staff were aware that the resident had a trauma history, including being locked in her room by a family member prior to admission, and that she had auditory and visual hallucinations, paranoia, and worsening behaviors around menstruation. Despite this, the care plan and behavior documentation did not clearly link her behaviors to the sexual interactions with male residents or identify new contributing factors after those events. The record shows two separate sexual incidents involving the resident and male residents. In the first incident, documented in the nursing notes, a male resident was found in the resident’s room with his hands down the front of her pants while she stated, "I don't like you." The male was redirected, and the provider adjusted medications, but documentation only stated that staff were to monitor the resident for increasing behaviors without specifying how long, what level of monitoring, or how staff were to keep her safe. In the second incident, staff heard the resident yelling "help me" and "get off" and found her fully clothed, lying crossways on a bed in a male resident’s room, with the male resident on top of her without pants and making thrusting movements. Staff separated the residents and returned her to her room, and again documentation only referenced closer monitoring without defining duration, intensity, or specific safety measures. Behavior review notes from several months showed persistent and escalating behaviors: wandering, pacing, entering other residents’ rooms, refusing redirection, yelling, crying, verbal hallucinations, paranoia, refusing medications and care, physical and verbal aggression toward staff, slamming and banging on doors, furniture, and walls, and attempts to pull her pants down in common areas. After the sexual incidents, new behaviors such as having her hands in her pants and attempting to remove clothing in public areas appeared, along with increased agitation, refusal of meals and medications, and statements that people were trying to kill or be mean to her. The behavior review identified triggers such as incontinence, reportable events, shingles, dental pain, clothing preferences, and phone calls with family, and listed non-pharmacologic interventions like snacks, one-on-one time, walking with staff, back rubs, aroma therapy, warm towels, and use of different staff. However, the care plan and behavior documentation did not incorporate the sexual encounters as triggers, did not identify prior sexual abuse as a trauma factor, and did not specify any enhanced supervision or monitoring level to protect the resident from further harm related to her wandering and sexually related interactions. The care plan for cognitive loss/dementia and psychosocial well-being included general interventions such as providing consistent caregivers, encouraging expression of feelings, and assisting the resident to avoid trauma triggers, with trauma history listed as car accidents, fires, heart attacks, deaths in the family, and the murder of an aunt. There was no mention of sexual trauma or the recent sexual incidents as part of her trauma profile. Behavioral symptom interventions, many of which were not initiated until after the period of escalating behaviors, focused on pain assessment, use of different staff, aroma therapy, warm towels, and recognition that menstruation worsened behaviors. Medication reviews showed multiple antipsychotic and psychotropic adjustments, including Abilify, Seroquel at various doses, Haloperidol, and PRN Ativan, with documentation that Seroquel changes had little to no effect on her behaviors. Despite ongoing documentation of high-risk behaviors and two documented sexual encounters with male residents, the facility did not develop or document a clear, individualized monitoring and supervision program specifying the level, duration, and methods of oversight needed to maintain the resident’s safety in relation to her wandering and sexual encounters.
Failure to Timely Report Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to report an incident of suspected abuse within 24 hours as required by its policy and staff-stated procedures. During interviews, staff members B and C stated that incidents must be reported within 24 hours and that investigations begin as soon as a reportable event is known, with annual abuse training and additional in-services on abuse and reporting timelines. Staff member A stated that the administrator, DON, and Social Services are responsible for obtaining statements from staff and residents, and confirmed that the time frames for reporting to the State Survey Agency are 2 hours for incidents involving serious bodily injury and 24 hours for incidents without serious bodily injury, with investigation findings due within 5 days. Record review showed that an incident of resident-to-resident abuse involving an altercation between residents #8 and #10, which occurred on 8/16/25, was not reported to the State Survey Agency until 8/18/25, exceeding the 24-hour reporting requirement. Review of the facility’s policy titled “Mandatory Reporting for Montana Nursing Facilities” confirmed that resident-to-resident abuse must be reported within 24 hours of discovery, that there is a 2-hour reporting requirement for crimes resulting in serious bodily injury, and that investigation results must be sent to the state agency within 5 working days of receipt of the abuse report. Despite these established policies and staff awareness of the required timelines, the facility did not submit the abuse incident involving residents #8 and #10 within the mandated 24-hour period from the date of the incident.
Inadequate Infection Control Measures During COVID-19 Outbreak
Penalty
Summary
The facility failed to implement adequate infection prevention and control measures during a COVID-19 outbreak. Observations revealed that visitors were not screened for COVID-19 symptoms upon entering the building, despite the presence of a sign-in log and N-95 masks at the entrance. Staff member J confirmed that no screening was in place, contrary to the facility's policy requiring active or passive screening. Additionally, transmission-based precaution signage was absent on the doors of COVID-19 positive residents, which led to staff being unaware of the specific precautions required. The facility also failed to practice proper hand hygiene during a laundry pass. Staff member G was observed distributing clothing to residents without performing hand hygiene before entering or after exiting resident rooms. Despite being educated on hand hygiene practices, staff member G admitted to forgetting the protocol. This oversight was in violation of the facility's hand hygiene policy, which mandates hand hygiene before and after entering resident rooms. Furthermore, the facility did not follow enhanced barrier precautions for residents with indwelling medical devices. Observations showed that resident #42, who had a foley catheter, did not have the required signage or personal protective equipment in place. Staff members were unsure why the necessary indicators were missing, despite the facility's policy and CDC guidelines requiring enhanced barrier precautions for residents with such medical devices.
Failure to Document COVID-19 Vaccine Declinations and Education
Penalty
Summary
The facility failed to document resident declinations and provide education regarding the COVID-19 vaccine for two of the five sampled residents. Resident #11 and Resident #27's preventive health care reports indicated that their resident representatives refused the administration of the COVID-19 vaccination. However, the facility did not provide signed declinations for these residents when requested during the survey. Additionally, staff member J confirmed that there were no signed declinations or documentation of education provided to the resident representatives for these residents. The facility's policy requires that if a resident or responsible party refuses an immunization, it must be documented in the permanent medical record, and the resident or responsible party should be provided with an education program and offered the immunization annually.
Failure to Implement Nutritional Interventions for Resident at Risk of Weight Loss
Penalty
Summary
The facility failed to follow outlined interventions for a resident who was at nutritional risk for weight loss. Observations revealed that the resident was not consuming meals provided, with a full breakfast tray left untouched and later removed while the resident was asleep. On another occasion, the resident was seen pushing food around without eating and later left her lunch untouched without any staff present to encourage or cue her to eat. The resident's care plan indicated she required encouragement during mealtimes and preferred finger foods due to her short attention span and frequent ambulation. The resident experienced a severe weight loss of 9.2% over three months, dropping from 106.4 lbs to 96.6 lbs. The facility's policy required weekly weight monitoring for residents with weight loss, but the resident's weight was only recorded monthly. A staff member mentioned that a new biweekly Resident at Risk meeting had identified the resident's significant weight loss, but the interventions were not effectively implemented, as evidenced by the observations of the resident's meal consumption.
Failure to Label and Date Food in Resident Refrigerator
Penalty
Summary
The facility failed to ensure that food items placed in the unit's nourishment refrigerator were properly dated and labeled with a resident's name. During an observation, an unlabeled and undated Tupperware container was found in the resident nourishment refrigerator, containing a homemade, unknown yellow liquid substance. There was no indication of which resident the food belonged to or how long it had been in the refrigerator. In an interview, a staff member stated that it was the responsibility of housekeeping to clean refrigerators in the resident common areas and mentioned that family members often placed items in the refrigerator without staff knowledge. The facility's policy on the use and storage of food brought in by family or visitors required all prepared food items to be labeled with content and dated, and consumed within three days, or else discarded by facility staff.
Failure to Administer Pneumococcal Vaccine
Penalty
Summary
The facility failed to ensure that a resident received, or had the opportunity to receive, the pneumococcal vaccine series. The immunization record for the resident showed that they had received one pneumococcal vaccine in 2018, but it did not specify the type of vaccine administered. A document titled 'Pneumococcal Vaccine Informed Consent/Decline' indicated that the resident's representative had consented for the resident to receive pneumococcal vaccines in 2024. During an interview, a staff member admitted that the facility did not keep pneumococcal vaccines in-house and had not yet arranged a vaccination clinic, citing being behind on reviewing immunizations. The facility's policy stated that residents should be assessed for vaccine eligibility within five working days of admission and offered the vaccine, but this was not adhered to in this case.
Failure to Monitor Cognitively Impaired Resident Leads to Elopement
Penalty
Summary
The facility failed to adequately monitor a cognitively impaired resident with a known history of elopement attempts, resulting in the resident leaving the building unsupervised. The incident was reported to the State Survey Agency after the resident was found alone at a nearby school playground. Staff interviews revealed that the resident was not residing in a secure unit, and there was a lack of awareness among staff members about the resident's elopement risk and the interventions in place to prevent such incidents. The resident in question had a history of wandering and required continuous supervision due to cognitive impairments, including fetal alcohol syndrome, schizophrenia, and moderate intellectual disability. The resident's care plan included interventions such as providing education on the importance of not leaving the facility, using verbal cues and gentle touch to redirect exit-seeking behaviors, and ensuring the resident did not accidentally follow visitors or pets out of the building. Despite these measures, several staff members were unaware of the resident's risk and the necessary interventions. Interviews with staff members indicated a lack of communication regarding residents at risk of elopement and their specific interventions. The facility had an elopement book intended to inform staff of at-risk residents, but it was not easily accessible, and several staff members were unaware of its contents. Additionally, the facility had not yet implemented an elopement huddle in morning meetings to improve communication about elopement risks, contributing to the oversight that allowed the resident to leave the facility unsupervised.
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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