Whitefish Care And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Whitefish, Montana.
- Location
- 1305 E 7th St, Whitefish, Montana 59937
- CMS Provider Number
- 275132
- Inspections on file
- 32
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 33
Citation history
Health deficiencies cited at Whitefish Care And Rehabilitation during CMS and state inspections, most recent first.
Nursing staff failed to consistently obtain weekly weights and did not recognize severe weight loss in a resident, despite physician orders. Multiple residents were not properly monitored or tracked for hydration status, resulting in hospitalizations for dehydration-related conditions. Staff interviews revealed confusion about responsibilities and inconsistent documentation of food and fluid intake, with hydration tracking removed from the charting system for most residents.
Nursing staff did not consistently assess, monitor, or document a resident’s clinical decline, including changes in mental status, vital signs, intake, and weight. This lack of documentation and communication led to the resident developing severe complications such as dehydration, acute renal failure, and sepsis, ultimately resulting in hospitalization.
Multiple residents and family members reported that staff frequently failed to address all resident needs, displayed poor attitudes, and sometimes mocked or used inappropriate language toward residents. Observations and grievance records revealed instances of staff refusing reasonable requests, neglecting basic care, and making insensitive remarks, leading to residents feeling disrespected and uncared for. These actions and inactions resulted in a lack of confidence in the grievance process and fear of retaliation among residents.
Several residents did not consistently receive or have documented their scheduled showers, with gaps in care and incomplete records. Family members and residents reported unmet hygienic needs, missed showers, and concerns about safety and documentation practices. Staff interviews and record reviews confirmed inconsistencies between paper and electronic documentation, and facility protocols for shower provision and refusal documentation were not reliably followed.
Multiple residents experienced unmet needs and safety concerns due to inaccessible or non-functional call lights, including one resident unable to locate his call light, a wheelchair-bound resident left unattended in a shower room without a reachable call system, and several residents reporting long wait times or repeated requests for assistance. Staff interviews and facility records confirmed frequent call light malfunctions and numerous related grievances.
Three residents were found to have unclean rooms, with visible dirt and garbage such as paper and medical items under beds and in living areas. Residents and staff reported inconsistent cleaning practices, and facility cleaning records were incomplete or missing for the relevant days.
A resident who was unable to independently perform oral care did not receive assistance with teeth brushing as required, despite reminders and staff awareness. Interviews revealed inconsistent ADL support among CNAs, and the facility's policy to provide necessary hygiene services for dependent residents was not followed.
A staff member who was not wound certified did not follow physician orders for a resident's wound care, applying an unprescribed calcium alginate dressing and failing to perform proper hand hygiene during the dressing change.
Surveyors found that the facility failed to maintain accident-free areas and provide adequate supervision, including leaving a wheelchair-bound resident unattended in a shower room without a call light, not ensuring fall prevention interventions such as fall mats and accessible call lights for a high-fall-risk resident, and not providing consistent hydration or oxygen for another resident who experienced multiple falls with head injuries.
A resident with a dental abscess did not receive necessary dental care due to lack of coordination among staff regarding insurance coverage and payment resources. The resident's dental procedure was canceled after staff believed payment could not be arranged, despite the facility having resources and the resident's Medicaid status pending. This led to ongoing dental infection, pain, difficulty eating, and significant weight loss.
The facility did not provide timely COVID-19 vaccination to two residents who later became ill, despite requests and expressed willingness to receive the vaccine. Staff cited physician recommendations and vaccine unavailability from the pharmacy as reasons for the delay, and documentation for vaccination consent or declination was missing for one resident. The outbreak began before vaccines were available, and most residents were only offered the vaccine after the outbreak had started.
A suspected sexual abuse event occurred between two residents, where one was found in another's room with inappropriate contact. Although staff notified police shortly after the incident, the required report to the State Survey Agency was not submitted within the mandated two-hour window, instead being sent over 21 hours later. Staff interviews indicated misunderstanding of the regulatory reporting timelines.
A facility failed to thoroughly investigate and implement protective measures after a resident-to-resident sexual incident. Staff did not provide targeted monitoring for sexual behaviors or update the care plan to address these behaviors, and there was no evidence of additional staff education on abuse prevention following the event.
A resident's care plan was not updated to address sexual behaviors directed towards others, despite an incident involving inappropriate contact between two residents. The care plan only included interventions for bipolar disorder symptoms and did not address the new behavioral concern, contrary to facility policy requiring care plan revisions after a status change.
The facility did not maintain documentation showing that staff received education on COVID-19 vaccination, were offered information about obtaining the vaccine, or had their vaccination status recorded, as confirmed by staff interviews and the absence of records when requested.
A nurse pre-poured medications into unlabeled cups and stored them in the medication cart, then administered these medications to multiple residents without proper labeling or verification. The nurse also documented medications as given on the MAR before actual administration and transferred pills between unlabeled cups, contrary to facility policy requiring one-at-a-time administration and post-administration documentation.
Staff did not consistently follow infection control protocols, including failure to use required gowns during enteral medication administration, inadequate hand hygiene before and between glove changes during medication administration and wound care, improper handling of wound care supplies, and returning a cigarette from the floor to a resident's possession without hand hygiene. These actions were not in accordance with facility policies and were confirmed through direct observation and staff interviews.
Three residents who had consented to pneumococcal vaccination did not receive the appropriate vaccine, as documented in their medical records. In two cases, no pneumococcal vaccine was administered after consent, and in another, the recommended Prevnar20 was not given despite prior PPSV23 administration. Staff reported limited vaccine documentation and were awaiting access to the state immunization system to update records.
Two residents experienced a lack of dignity when one witnessed the removal of a deceased resident through a populated hallway, causing emotional distress, and another was left waiting in wet clothing after an incontinence episode, leading to frustration and anger. Staff did not follow established privacy protocols or timely incontinence care as outlined in care plans and facility policy.
Staff failed to supervise and document the self-administration of medications for two residents, resulting in unsupervised access to pain pills and a rescue inhaler left at the bedside. Facility policy required RN assessment, documentation, and care plan updates for self-administration, but these steps were not completed or reflected in the residents' records.
A resident's advance directives and code status were not accurately maintained or readily accessible to staff, resulting in conflicting POLST forms and uncertainty among staff regarding the resident's current wishes. Staff relied on electronic records and binders, but inconsistent documentation and lack of up-to-date information led to confusion during care and emergency planning.
Three residents were affected by unclean wheelchairs and unpainted, non-cleanable surfaces in their rooms and bathrooms. Observations showed wheelchairs with caked-on debris and walls with chipped or missing paint, creating unsanitary conditions. Staff interviews revealed that maintenance and cleaning tasks were not completed as required due to prioritization of other duties and lack of time, and maintenance logs showed few repairs had been made.
A resident's care plan was not updated to reflect a change from full code to DNR status as documented in the most recent POLST. Staff reported that care plan updates were assigned during morning meetings, but the care plan continued to show outdated information despite the resident's new DNR election.
Two residents who required assistance with bathing did not receive regular showers as scheduled, resulting in feelings of uncleanliness and dissatisfaction. Observations showed both had oily hair, and records confirmed infrequent bathing over a 30-day period. Staff interviews indicated that CNAs often missed baths due to time constraints, despite facility policy requiring regular assistance with hygiene.
A staff member did not follow provider orders for administering medications through a gastrostomy tube for a resident, failing to check tube placement by auscultation and not using the correct amount of water flushes as ordered. All medications were given together instead of one at a time with appropriate water flushes, contrary to both provider orders and facility policy.
Two residents did not receive medications as ordered, including one who was given midodrine without confirmation of food intake and another who received multiple medications via PEG tube in a single cup with insufficient water flushes. Staff admitted to not following prescriber orders, resulting in a medication error rate of 20%.
A nurse administered both a scheduled dose of long-acting insulin and an additional dose of fast-acting insulin intended for another resident to a single resident, due to distraction and improper labeling of insulin pens. The error resulted in the resident being sent to the ER for continuous glucose monitoring. Environmental factors such as poor lighting and noise contributed to the incident, and the facility's medication administration policies were not followed.
A resident and their representative reported missing personal items, including clothing, after discharge. Despite notifying the facility, no response or investigation was documented, and the required inventory list was not found in the medical record. The facility's grievance log did not reflect the complaint, and staff could not provide the necessary documentation, indicating a failure to follow established policies for inventory and grievance handling.
Two residents experienced cardiac arrest events and expired in the facility due to the lack of staff CPR certification, inadequate training, and missing essential supplies such as Ambu bags and protective barriers on the crash cart. Staff were unclear about their responsibilities, the crash cart was not easily accessible or routinely checked, and there was no process in place to track CPR certifications or ensure emergency supplies were available.
The facility failed to maintain accessible and properly stocked crash carts, resulting in delays in emergency respiratory care for two residents. Staff were unable to locate essential supplies such as Ambu bags and barriers during code situations, and there was no clear responsibility or documentation for checking or restocking crash carts. The facility's assessment and policies did not adequately address respiratory care services, equipment, or staff training related to respiratory emergencies.
The facility did not update its Facility Assessment to reflect the addition of a pulmonary program, omitting key information about respiratory care services, staffing changes, equipment, staff training, and necessary medical supplies. Staff interviews confirmed the program had been in place for about a year, but the assessment failed to address these changes, increasing the risk for residents needing pulmonary care.
The facility did not ensure staff received adequate training on supply locations, ordering procedures, crash cart management, or CPR certification. Multiple staff, including contracted personnel, reported not being shown where supplies were kept, how to order them, or how to restock the crash cart. Some staff had not received CPR training or certification, and there was no clear policy or documentation outlining these requirements.
The facility did not provide required infection prevention and control training to new, existing, and contracted staff, and several staff members were unaware of the Infection Preventionist's identity. The facility had a gap in Infection Preventionist coverage, and staff education on infection control policies and procedures was not conducted as outlined in facility protocols.
Licensed staff administered medications with specific blood pressure and pulse parameters without consistently checking or documenting vital signs, resulting in multiple instances where medications were given outside of ordered parameters for three residents. Staff interviews confirmed a lack of adherence to physician orders and facility policy regarding medication administration.
Three residents received medications outside of physician-ordered parameters, including administration of Midodrine and Atenolol without appropriate blood pressure or pulse checks or despite readings that should have resulted in the medication being held. Staff interviews confirmed knowledge of the requirement to check vital signs prior to administration, but this was not consistently followed or documented.
Staff failed to consistently perform hand hygiene and implement enhanced barrier precautions, with multiple staff members entering and exiting resident rooms, handling medication and meal trays, and providing care without washing hands or using sanitizer. Several staff were unaware of infection prevention protocols or which residents required enhanced precautions, and there was a gap in infection prevention oversight due to staff turnover. Facility records showed limited recent training on infection control.
Two residents with indwelling Foley catheters did not receive proper daily catheter care, resulting in discomfort, foul odors, and visible signs of inadequate hygiene at the catheter site. Staff interviews and record reviews revealed inconsistent performance and documentation of catheter care, with one resident's care not recorded due to a missing physician order. Facility policy required catheter care every shift, but this was not consistently followed.
The facility failed to ensure staff roles were clear and within their scope, leading to inappropriate care planning and medication recommendations. A staff member without clinical qualifications recommended medications, and there was inadequate follow-up on residents leaving AMA. Additionally, behavioral health concerns were poorly documented, and policies against substance use were not enforced.
The facility failed to properly document and communicate the circumstances surrounding AMA discharges for two residents. One resident was not informed of their rights or offered transportation, and APS was not contacted. Another resident's discharge was postponed without clear communication, leading to frustration. Staff interviews revealed inconsistencies in handling AMA discharges, and the facility's policy on AMA discharges was not followed.
The facility failed to complete timely MDS assessments for several residents, with delays in Quarterly, Annual, and Discharge MDS assessments. New MDS coordinators were behind on their tasks and unsure of completion timelines, leading to overdue assessments. A lack of oversight and consistent nursing administration contributed to the issue.
The facility failed to submit MDS information within the required 14 days for several residents due to the inexperience of new MDS coordinators and lack of oversight. Quarterly, Annual, and Discharge MDS assessments were overdue by 10 to 61 days, violating the facility's policy for timely transmission to the CMS system.
The facility's quality assurance committee did not address a high number of AMA discharges, with 21 residents leaving without physician approval or a care plan. A resident reported feeling unsafe, encountering rude staff, and poor food quality, with no follow-up after their AMA discharge.
The facility failed to enforce its smoking policy, allowing a resident to smoke too close to the building and another to keep tobacco in their room. Additionally, two residents with severe cognitive impairment were not properly assessed for smoking supervision, contrary to policy requirements.
The facility failed to inform two residents about the risks and benefits of their psychotropic medications. One resident was unaware of the names, side effects, or benefits of his mood medications, while another resident, who manages her own medical decisions, was not informed about the side effects of her anxiety and depression medications. Consent forms lacked signatures, and the staff member responsible for the forms could not confirm discussions about risks and benefits, nor did he have a clinical background.
The facility failed to accurately code MDS assessments for two residents, omitting psychiatric diagnoses and incorrectly documenting psychotropic medication use. One resident's MDS did not reflect anxiety and depression diagnoses, and another's did not mark any psychiatric diagnoses despite medication use. Staff interviews revealed unawareness of these inaccuracies, contrary to facility policy requiring accuracy attestation.
A facility failed to provide an appropriate discharge plan for a resident, resulting in insufficient documentation and lack of communication with the resident and caregiver. The resident, requiring daily wound care and antibiotics, was initially informed of a discharge date, but later told it could not proceed, causing frustration and consideration of leaving AMA. Staff acknowledged the need for improvement in the discharge process.
A facility failed to provide necessary behavioral health services to a resident with anxiety and major depressive disorder. The resident's last psychological evaluation was over three years ago, and no services were offered during their stay. Staff interviews revealed inadequate documentation and follow-up on behavioral health issues, with concerns about residents' behaviors not being addressed. The facility's policy required behavioral health services, but these were not adequately provided or documented.
A resident with a pressure ulcer requiring a wound vac did not receive proper care, leading to deterioration of the wound. Staff failed to document issues with the wound vac, such as maintaining a seal and drainage amounts. The wound nurse was on leave, and the staff responsible for wound care struggled with documentation and changed orders without proper records. The facility's policy on wound assessments and documentation was not consistently followed.
The facility failed to conduct thorough investigations for multiple abuse and neglect allegations involving residents. Incidents included a CNA allegedly forcing a resident to drink water, a nurse verbally assaulting a resident, and neglect of care resulting in a leaked foley bag. Documentation was incomplete, lacking details such as identities of alleged abusers, interviews, and protective measures. The facility's policy on abuse, neglect, and exploitation was not followed.
The facility failed to report allegations of abuse within the required 24-hour timeframe for two residents. One resident complained of being verbally assaulted by a nurse, and another was involved in a verbal altercation with a staff member, leading to police involvement. Both incidents were reported late to the State Survey Agency, contrary to the facility's policy requiring immediate notification.
Failure to Monitor and Document Nutrition and Hydration Status
Penalty
Summary
Facility nursing staff failed to obtain weekly weights and did not recognize severe weight loss in one resident, despite physician orders to monitor weight weekly and reweigh if there was a significant change. The resident experienced a 14-pound weight loss over a short period, with no weight documented for three weeks. Staff interviews revealed that the resident often refused weights, and when finally weighed, a significant decline was noted. The resident also had poor dentition, a dental infection, and was experiencing decreased appetite, nausea, and loose stools, all of which contributed to poor intake. Staff were not consistently monitoring or documenting food and fluid intake, and there was confusion about responsibilities for monitoring hydration and nutrition. Additionally, the facility failed to ensure that residents were monitored and tracked for maintenance of proper hydration status. Multiple residents were hospitalized with conditions related to dehydration, including acute renal failure, hyponatremia, and hypovolemia. Staff interviews indicated that hydration status was not routinely tracked or monitored unless residents showed overt signs of dehydration. Documentation of fluid intake was inconsistent or missing, and some staff were unaware of the need to monitor for the effects of diuretic use beyond checking for edema. The facility's own policy required systematic assessment and monitoring of hydration status, but this was not consistently implemented. Staff reported that hydration tracking had been removed from the charting system for most residents, and only a few had active hydration monitoring. There was a lack of clear communication and accountability regarding who was responsible for monitoring and documenting hydration and nutritional intake, leading to missed signs of decline and delayed interventions for residents at risk.
Failure to Ensure Nursing Staff Competency in Resident Assessment and Documentation
Penalty
Summary
Nursing staff failed to demonstrate appropriate competencies in assessing, monitoring, and recognizing clinical changes in a resident who experienced ongoing clinical decline. The resident, an elderly female, was admitted with multiple health concerns including a dental infection, use of a diuretic for congestive heart failure, and was at risk for weight loss. Over the course of her stay, she developed recurrent vomiting, hypotension, altered mental status, and ultimately required hospitalization for aspiration pneumonia, severe hyperkalemia, acute renal failure, and sepsis. Staff interviews and record reviews revealed that changes in the resident’s condition, such as increased confusion, falls, and weakness, were not consistently documented or communicated among the care team. Daily skilled nursing assessments were not completed as required, and there was a lack of clear documentation regarding the onset and progression of the resident’s decline. Further review showed that vital signs, intake and output, and weights were not consistently recorded in the medical record, despite physician orders and facility policies requiring such documentation. The resident experienced a significant, unmonitored weight loss and there was no evidence that the dietitian or physician was notified of her declining intake. Staff members reported that they relied on their own assessment and critical thinking skills due to the absence of clinical pathways, and that training on assessment skills was primarily delivered through computer modules or infrequent staff meetings. Additionally, the facility’s electronic health record system had issues with hydration tracking, and some documentation was deleted or not entered, further impeding the ability to monitor the resident’s status. The facility’s policies required accurate, complete, and timely documentation of assessments, observations, and services provided, as well as systematic approaches to optimize hydration status. However, these protocols were not followed for this resident. Staff interviews confirmed that documentation of the resident’s change in condition, interventions, and communication with providers was lacking or missing entirely. The failure to document and respond appropriately to the resident’s clinical changes resulted in her developing severe complications and requiring hospitalization.
Failure to Ensure Resident Dignity and Respect Due to Deficient Staff Attitudes and Communication
Penalty
Summary
The facility failed to ensure that residents were treated with dignity, respect, and a customer service approach, as evidenced by multiple resident and family interviews, observations, and grievance reviews. Residents reported that staff often did not address all their needs during care, such as not assisting with oral hygiene or washing in the morning, and sometimes made residents feel like they were a burden. Several residents described staff as having poor attitudes, lacking caring mannerisms, and being dismissive or even mocking toward residents. One resident recounted witnessing a CNA cussing at a hospice patient in pain, while others described staff as being loud, using inappropriate language, and making residents feel disrespected or uncared for. Grievance records further documented concerns about staff approach, including staff refusing reasonable food substitutions, failing to provide timely incontinence care, and making racially insensitive or inappropriate remarks. Residents expressed a lack of confidence in the grievance process and reported fear of retaliation if they voiced concerns. Family members also noted that staff were not invested in resident care, leading to increased stress and concerns about the quality of care provided. These findings collectively demonstrate a pattern of deficient staff behavior and communication that compromised residents' rights to dignity, self-determination, and respectful treatment.
Failure to Consistently Provide and Document Scheduled Showers
Penalty
Summary
The facility failed to consistently provide and document scheduled showers for four of twelve sampled residents. Interviews and record reviews revealed that one resident's hygienic needs, including showering, shaving, hair trimming, and fingernail clipping, were not met frequently enough, resulting in a family member performing these tasks. Documentation showed gaps of up to seven days without a recorded shower or refusal, despite a set schedule. Another resident had only one documented shower refusal since admission, with no other records of completed or refused showers, and inconsistencies were found between paper and electronic documentation. Staff interviews confirmed issues with documentation practices, including reliance on paper records and double documentation, which contributed to the inconsistencies. Two additional residents expressed concerns about missed scheduled showers, with one reporting being left unattended in the shower room for 45 minutes without access to a pull cord, despite being wheelchair-bound. Review of the shower schedule and electronic health records showed significant gaps between documented showers, sometimes up to 14 days. Facility policy required showers to be provided per schedule or resident request, with documentation on both paper and electronic systems, and a specific process for documenting refusals. However, these protocols were not consistently followed, leading to incomplete records and unmet resident care needs.
Failure to Ensure Accessible and Functional Call Light System
Penalty
Summary
The facility failed to ensure that call lights were consistently available, accessible, and functional for multiple residents, resulting in unmet needs and safety concerns. Observations revealed that one resident, identified as a fall risk, was unable to locate his call light, which was draped over a fall mat and lacked a clip for proper placement. Staff were uncertain about the correct placement of call lights for residents with dementia. In the shower room, a wheelchair-bound resident was left unattended for an extended period without access to a reachable call light, as the pull cord was missing and the call light station was obstructed by shower chairs. Staff confirmed that residents should not be left alone in the shower room, and the lack of accessible call lights posed a safety risk. Interviews with several residents indicated prolonged wait times for call light responses, with some reporting waits of up to four hours or having to repeatedly request assistance. Residents described situations where call lights were not working, had to be pulled from the wall, or were not reachable due to their physical limitations. Staff interviews and facility work order records showed that multiple call lights required repairs within a single month, and some staff expressed concern about the frequency of these issues. Facility grievance records further documented complaints about non-functional call lights and delayed responses, with some residents' needs not being met even after staff responded to the call light.
Failure to Maintain Clean and Homelike Resident Rooms
Penalty
Summary
The facility failed to maintain a clean and homelike environment for three of twelve sampled residents, as evidenced by multiple observations and interviews. One resident's room had visible dirt and pieces of paper under the bed, with staff and the resident confirming that garbage was often present and that cleaning under beds was not routinely performed. Another resident's room had visible dirt near the wheelchair area, and the resident noted inconsistent cleaning depending on the staff member, while a staff member admitted to only cleaning as needed. A third resident had oxygen tubing ear protectors and a green piece of garbage under the bed on consecutive days. Facility cleaning records were incomplete or missing for the relevant dates, further indicating lapses in routine cleaning practices.
Failure to Provide Assistance with Oral Care for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident who required assistance with activities of daily living (ADLs), specifically oral care, did not receive help with teeth brushing throughout the day. The resident reported on multiple occasions that he had not brushed his teeth and that staff had not assisted him, despite a visible reminder in his room indicating the need for oral care as recommended by speech therapy. Staff interviews confirmed inconsistent provision of ADL care, with some CNAs performing all required tasks and others not. The facility's policy states that residents unable to perform ADLs should receive necessary services to maintain personal and oral hygiene, but this was not followed in the resident's case.
Failure to Follow Physician Wound Orders and Proper Hand Hygiene
Penalty
Summary
A deficiency occurred when a staff member, who was not wound certified, failed to follow physician orders for wound care for one resident. During a dressing change, the staff member applied calcium alginate to the resident's wound, despite the physician's order specifying to cleanse with wound cleanser and apply a collagen pad secured with a dry dressing. The staff member stated they added the calcium alginate because the wound had not been healing and believed it would help with drainage, even though this was not part of the prescribed treatment. Additionally, the staff member did not perform proper hand hygiene after removing the old dressing and before applying the new one. The facility's policy required wound treatments to be provided in accordance with physician orders.
Failure to Prevent Accidents and Ensure Adequate Supervision
Penalty
Summary
The facility failed to ensure that a shower room was free from accident hazards and provided adequate supervision, as evidenced by a wheelchair-bound resident being left alone in the shower room for 45 minutes without access to a call light pull cord. The call light station was not only missing the required pull cord but was also out of reach due to obstructing shower chairs, creating a hazardous environment. Staff confirmed that residents should not be left unattended in the shower room and that the lack of call light accessibility was unsafe. Another resident, identified as having a high risk for falls, did not consistently have fall prevention interventions in place. Observations revealed that the resident's fall mat was folded and not positioned on the floor as required, and the call light was not within reach, with its button hidden behind the mat. The resident was observed attempting to get out of bed without assistance, and the bed was found to be unlocked on multiple occasions. Staff interviews indicated that interventions such as ensuring the call light was within reach and the fall mat was in place were not always followed, and concerns about the adequacy and consistency of fall prevention measures were raised by both staff and family. A third resident experienced multiple falls, some resulting in head injuries, with documentation indicating possible causes such as orthostatic hypotension, dehydration, and a potential seizure. Despite these incidents, observations showed that the resident did not have water readily available at the bedside and was not using prescribed oxygen. The facility's fall prevention policy required individualized interventions and routine rounding, but the lack of consistent implementation of these measures contributed to the resident's repeated falls and injuries.
Failure to Provide Necessary Dental Services for Resident with Dental Abscess
Penalty
Summary
The facility failed to provide necessary dental services for a resident who had a documented dental abscess and was awaiting Medicaid approval for insurance coverage. Upon admission, the resident had a known dental infection and was prescribed antibiotics, with a follow-up dental appointment scheduled prior to hospital discharge. Staff interviews and record reviews revealed that the social services assessment identified dental needs, but no dental visit request was filed, and staff were unaware of the abscessed tooth. When the dental office contacted the facility regarding payment for the scheduled extraction, staff found that the resident lacked dental insurance and was unable to pay the $1200 fee. The appointment was subsequently canceled after discussing the cost with the resident, and staff were not aware of available facility resources or the resident's pending Medicaid status. Further review of the resident's records showed ongoing dental infection, difficulty chewing, and significant weight loss since admission. The care plan included a focus on dental care, but no arrangements were made for the necessary procedure due to the perceived lack of payment options. Communication breakdowns between nursing, social services, and the business office contributed to the failure to secure dental care, despite the resident's Medicaid approval being effective shortly after admission. The deficiency resulted in the resident experiencing pain, difficulty eating, and severe weight loss.
Delayed COVID-19 Vaccination and Documentation Failures During Outbreak
Penalty
Summary
The facility failed to provide COVID-19 vaccines in a timely manner to eligible residents, specifically two residents who subsequently contracted COVID-19. One resident reported being asked about receiving the vaccine approximately a month prior but had not received it despite expressing a desire to be vaccinated. Another resident's family member stated they had repeatedly requested the vaccine for the resident, but no consent or declination form was provided, and the vaccine was not administered. The family member also reported a lack of communication from the facility during a COVID-19 outbreak, leading them to contact the health department for information. Staff interviews revealed that vaccines were not administered because the primary physician recommended waiting until residents were off isolation, and the facility did not have COVID-19 vaccines on hand due to unavailability from the pharmacy. Documentation showed that one resident was offered and received the vaccine, while another had only been asked about it but had not received it. The facility was unable to provide vaccination or declination documentation for one resident. The COVID-19 outbreak began before vaccines were available at the facility, and staff reported that a significant portion of the building had been offered the vaccine only after the outbreak had started.
Failure to Timely Report Suspected Sexual Abuse Incident
Penalty
Summary
The facility failed to submit an initial report to the State Survey Agency within the required two-hour timeframe following a suspected resident-to-resident sexual abuse incident involving two residents. According to the incident documentation, one resident was found in another resident's room by two staff members; the second resident was lying in bed with his brief undone while the first resident had her hand on his penis. The incident occurred at 1:30 a.m., but the report was not received by the State Survey Agency until over 21 hours later. Staff interviews revealed confusion regarding the reporting requirements, with one staff member incorrectly believing that only incidents involving serious bodily injury needed to be reported within two hours, and others could be reported within 24 hours.
Failure to Investigate and Prevent Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation and implement necessary protective measures following a resident-to-resident sexual incident involving two residents. On the date of the incident, one resident was found in another resident's room with her hand on his penis, and the second resident's brief was undone. Both residents were assessed for injury, and the incident was reported to the appropriate staff. However, the facility's investigation documents did not include evidence of staff education for abuse prevention related to the incident, nor did they show that monitoring for sexual behaviors was implemented for the initiating resident. Additionally, although staff were reportedly charting behavior monitoring for the initiating resident, there was no indication that sexual behaviors were specifically identified or targeted for ongoing monitoring. The care plan for the initiating resident referenced behavioral issues such as shouting and wandering, but did not address sexual behaviors, focus areas, goals, or interventions related to the incident. The most recent documented staff in-service training on abuse/neglect occurred three weeks prior to the incident, with no documentation of additional training provided after the event.
Failure to Update Care Plan for Sexual Behaviors
Penalty
Summary
The facility failed to update a resident's care plan to address sexual behaviors directed towards others, which could constitute abuse. Specifically, a review of a facility-reported incident showed that one resident was found in another resident's room, with the second resident's hand on the first resident's genitals. Despite this incident, the comprehensive care plan for the resident involved did not include any focus area, goals, or interventions related to sexual behaviors or the potential for sexual abuse towards others. The care plan only addressed manifestations of bipolar disorder, such as shouting and wandering, but omitted any mention of sexual behaviors. During an interview, a staff member confirmed that the resident's sexual behaviors had not been added to the care plan and acknowledged that such behaviors should have been care planned. Facility policies reviewed indicated that care plans are to be developed and revised upon a resident's status change, but this process was not followed in this case. The deficiency was identified through both interview and record review, with documentation supporting that the care plan was not updated as required.
Failure to Document Staff COVID-19 Vaccination Education and Status
Penalty
Summary
The facility failed to maintain required documentation regarding COVID-19 vaccination for staff members. Specifically, there was no evidence that staff had been provided education about the benefits and potential risks of the COVID-19 vaccine, nor that they had been offered information on obtaining the vaccine. During interviews, staff members confirmed the absence of documentation related to staff COVID-19 vaccination status or declination. Additionally, when a written request was made for documentation on five randomly selected staff members, the facility was unable to provide any records prior to the survey exit. Review of the facility's own policy indicated that such documentation was required, including education, offering of the vaccine, and recording of vaccination status.
Failure to Follow Professional Standards During Medication Administration
Penalty
Summary
Staff member Z failed to follow professional standards during medication administration by pre-pouring medications into unlabeled cups and storing them in the medication cart. During multiple observations, staff member Z administered medications to several residents from these unlabeled cups, stating she knew which medications belonged to which residents but could not find the residents at the time. She also admitted to marking medications as given on the Medication Administration Record (MAR) before actually administering them, acknowledging that this was not the correct procedure. On one occasion, staff member Z transferred pills from one unlabeled cup to another prior to administration, and at the end of her medication pass, there were still three unlabeled cups remaining in the cart for which she was unsure of the intended recipients. The facility's policy requires that medications be administered one at a time, observed for consumption, and signed off on the MAR only after administration. Staff member Z's actions, including pre-pouring, using unlabeled cups, and documenting administration before actual delivery, were inconsistent with these professional standards and facility policy. These practices were observed for nine residents during the medication pass, with staff member Z expressing confusion about the process and the identity of the medications in some cups.
Failure to Follow Infection Control Protocols During Medication Administration, Wound Care, and Resident Assistance
Penalty
Summary
Staff failed to adhere to infection prevention and control protocols in several instances involving multiple residents. During medication administration via a PEG tube for a resident under Enhanced Barrier Precautions (EBP), a staff member donned gloves but did not wear a protective gown as required for high-contact activities involving device care. The staff member later acknowledged that a gown should have been worn during the procedure. Facility policy specified that EBP includes the use of gowns and gloves during care activities such as feeding tube management. Hand hygiene practices were not consistently followed by staff during medication administration and wound care. One staff member did not sanitize hands between glove changes while administering medications via PEG tube, and another did not perform hand hygiene before donning gloves or between glove changes during wound care for a resident with multiple wounds. Additional staff members failed to perform hand hygiene before preparing or administering medications to several residents. Facility policies required hand hygiene before donning gloves and before medication administration, but these were not followed as observed. In wound care, a staff member placed supplies directly on unclean surfaces without protective barriers and used scissors stored in an unclean pocket to cut bandages, which were then applied to a resident's wound. Additionally, another staff member picked up a cigarette from the floor and returned it to a resident's cigarette box without performing hand hygiene. These actions were contrary to infection control procedures and facility policies, as confirmed by staff interviews and policy reviews.
Failure to Administer Pneumococcal Vaccines After Consent
Penalty
Summary
The facility failed to ensure that residents who had been screened and provided consent for pneumococcal immunizations actually received the vaccine. Specifically, three residents who had signed informed consent forms for the pneumococcal vaccine did not have documentation of receiving the vaccine in their electronic health records. For two of these residents, there was no record of the pneumococcal vaccine being administered after consent was obtained. For the third resident, although a previous dose of PPSV23 was documented, the recommended Prevnar20 vaccine had not been administered as per current CDC guidelines. During interviews, staff members reported that they had recently started working at the facility and noted that there was limited documentation available regarding resident vaccinations. They also indicated that they were waiting for access to the state immunization information system to update and verify the facility's vaccine records. The facility's policy requires a signed consent form prior to vaccine administration and specifies that the type of pneumococcal vaccine offered should align with CDC recommendations, but these procedures were not followed for the residents in question.
Failure to Maintain Resident Dignity During Postmortem Care and Incontinence Episode
Penalty
Summary
The facility failed to maintain resident dignity in two separate incidents. In the first incident, after a resident's death, two unidentified individuals removed the deceased resident on a stretcher covered with a blanket through a hallway where other residents and visitors were present. This action was observed by another resident, who expressed sadness and distress at witnessing the event. Staff later confirmed that the usual practice is to clear the hallway and use the closest exit to maintain privacy, as outlined in the facility's post-mortem care policy, but this was not followed in this instance. In the second incident, a resident who experienced an episode of incontinence was left waiting in wet clothing for assistance. The resident had activated the call light and reported that staff entered the room but only told him they would return, causing him frustration and anger. The resident's care plan indicated a need for dependent assistance by two staff for toileting and a check and change schedule every two hours, but the electronic medical record did not reflect this schedule. Staff confirmed the resident should be checked and changed every two hours.
Failure to Supervise and Document Resident Self-Administration of Medications
Penalty
Summary
Facility staff failed to properly supervise the self-administration of medications for two residents. One resident was observed with two blue pills, identified as Ibuprofen and Tramadol, left on the bedside table in a plastic medicine cup without staff present. The resident reported that some nurses would leave medications for later self-administration, while others would not. Another resident had a metered-dose inhaler left on the bedside table, which she stated was her rescue inhaler that she rarely used but preferred to keep in her room. In both cases, there was no staff supervision at the time the medications were accessible to the residents. Interviews with staff revealed inconsistent practices regarding medication administration and storage. Staff members indicated that facility policy required an RN assessment and documentation before allowing self-administration of medications, and that the MAR should reflect such authorization. However, there were no self-administration assessments or care plan documentation for the two residents involved. The facility's policy also required that medications not be left at the bedside unless authorized and that storage arrangements be documented in the care plan, which was not done for these residents.
Failure to Maintain Accurate and Accessible Advance Directives
Penalty
Summary
The facility failed to maintain an effective process to ensure that the most current and accurate code status and advance directives for a resident were readily known and available to staff in the event of an emergency. Multiple staff interviews revealed inconsistent knowledge about the location and content of the resident's advance directives and POLST forms. Staff reported that advance directives were requested on admission and updated during care conferences, with copies uploaded to the electronic medical record. However, it was discovered that a resident had completed multiple POLST forms with conflicting instructions—one indicating full code with brief CPR and another indicating DNR—without the facility having all relevant documents on file or clearly identifying the most current directive. The resident's son also indicated that advance directives had been completed and should be present in the resident's room, but these were not on file with the facility until staff made copies after the fact. Record review showed two different POLSTs uploaded in the electronic medical record, with no other advance directives present. The care profile listed the resident as full code/full treatment, while the physician's orders reflected an active order for full code and full treatment, with no other orders for advance directives or code status documented. Staff interviews indicated reliance on the electronic medical record and binders at the nurses' station for code status information, but the presence of conflicting documents and lack of clear, up-to-date information created confusion about the resident's actual wishes. The deficiency was identified for one resident out of a sample of thirty.
Failure to Maintain Clean and Homelike Environment for Residents
Penalty
Summary
The facility failed to maintain a clean, safe, and homelike environment for three sampled residents, as evidenced by multiple observations of unclean wheelchairs and unpainted, non-cleanable surfaces in resident rooms and bathrooms. Specifically, paint was chipped or missing on walls near beds and sinks, exposing drywall and creating surfaces that could not be properly cleaned. Residents expressed dissatisfaction with the appearance of their environment, noting that the condition of the walls was bothersome. Additionally, wheelchairs used by the residents were observed to have accumulated debris, including caked-on white and brown substances on the seats, footrests, and metal parts, which were not cleaned between observations on consecutive days. Interviews with staff revealed that maintenance requests for paint repairs were deprioritized in favor of fire life safety issues, and that routine cleaning of wheelchairs was assigned to night shift CNAs, who reported insufficient time to complete these tasks. Review of maintenance logs indicated a lack of documented work orders for paint repairs in the current year and minimal touch-ups in the previous year. The facility's own policy required routine inspections and immediate correction of identified issues, but these procedures were not followed, resulting in the observed deficiencies.
Failure to Update Care Plan After Code Status Change
Penalty
Summary
The facility failed to ensure the accuracy of a resident's care plan following a change in code status. Specifically, a resident's care plan initially indicated full code status based on the POLST in the referral packet, with interventions to request and review advance directives upon admission and at least quarterly. However, the most recent POLST, signed by the provider, indicated the resident had elected Do Not Resuscitate (DNR) status. Staff interviews revealed that care plan updates were typically handled by the affected department and assigned during morning meetings if needed, but the care plan was not updated to reflect the resident's current DNR status as documented in the latest POLST.
Failure to Provide Regular Showers to Dependent Residents
Penalty
Summary
Facility staff failed to provide regular showers to two residents who required assistance with bathing, as evidenced by observations and interviews. One resident, who had been in the facility for approximately seven months, reported that baths had not been consistent and expressed dissatisfaction with the use of dry shampoo as a substitute. Observation revealed the resident's hair was oily and stringy, and a review of the electronic medical record showed only two baths were provided in a 30-day period. The resident's care plan indicated a need for set-up assistance with showers or bathing. Another resident was observed with oily, matted hair and reported not receiving regular baths as scheduled, which made her feel unclean. This resident was supposed to receive baths twice weekly but had only one documented bath in the same 30-day period. Her care plan required limited to extensive assistance with showering, depending on her energy and fatigue levels. A staff member confirmed that CNAs were responsible for baths but often lacked time to complete them, resulting in missed showers. Facility policy required staff to assist residents with bathing according to requests or the facility schedule.
Failure to Follow Provider Orders for Medication Administration via Feeding Tube
Penalty
Summary
Staff member N failed to follow provider orders during the administration of medications via a gastrostomy tube (GT) for a resident. Specifically, the staff member did not check for correct placement of the GT by auscultation prior to administering medications, as required by the provider's orders. Instead, the staff member flushed the tube with 10 ml of water, administered all medications mixed together, and then flushed the tube again with 10 ml of water, using a total of 30 ml of water. The provider's orders specified that medications should be given one at a time with a 10 ml water flush between each medication, and that the tube should be flushed with 30 ml of water before and after medication administration, totaling 110 ml of water per administration. During an interview, the staff member acknowledged that the method used did not match the provider's written orders and that the total volume of water used was incorrect. Facility policy also required verification of tube placement before administering medications, which was not performed during the observed medication pass. The resident involved had an active order for medication administration via GT, and the deficiency was identified through direct observation, interview, and record review.
Medication Administration Errors Result in 20% Error Rate
Penalty
Summary
The facility failed to properly administer medications according to prescriber orders for two residents, resulting in a medication error rate of 20%. In one instance, a staff member administered midodrine 2.5 mg to a resident without confirming if the resident had eaten, despite the medication order specifying administration with meals. The staff member admitted to not knowing whether the resident had eaten and stated that nurses had told her it was acceptable to give the medication without food. Review of the facility's medication administration policy confirmed that medications are to be given as ordered by the physician, including at the right time. In another case, a staff member administered multiple medications via PEG tube to a resident by combining them in one cup and using only 30 ml of water, contrary to the provider's order, which required medications to be given one at a time with 10 ml water flush between each, and a total of 110 ml water per administration. The staff member acknowledged that she routinely administered the medications in this manner and did not follow the specific order for water flushes. These actions directly contributed to the facility's medication error rate exceeding the acceptable threshold.
Significant Medication Error: Insulin Administered to Wrong Resident
Penalty
Summary
A significant medication error occurred when a nurse administered both a scheduled dose of long-acting insulin and an additional dose of fast-acting insulin intended for another resident to a single resident. The nurse was distracted and brought two pre-filled insulin pens into the resident's room, one containing 18 units of long-acting insulin for the resident and the other containing 42 units of fast-acting insulin for the roommate. Both doses were given to the same resident, which was not in accordance with physician's orders or the facility's medication administration policy. The error was realized after administration, and the resident required immediate transfer to the emergency room for continuous glucose monitoring. Interviews and record reviews revealed that the insulin pens were not properly labeled, with labels only on the lids and not on the bodies of the pens. Contributing environmental factors included poor lighting and noise during the medication pass. The nurse involved had received initial training on medication management and injections, but direct observation of competency was not documented. Other staff members reported not receiving specific education regarding the incident at the time, and the facility's policies required adherence to the six rights of medication administration, which were not followed in this case.
Failure to Document and Investigate Resident Grievance Regarding Missing Personal Items
Penalty
Summary
The facility failed to maintain an accurate inventory of a resident's personal items and did not properly identify or investigate a grievance related to missing clothing following the resident's discharge. Interviews with staff and the resident's representatives revealed that concerns about missing items, including a gray hooded jacket, pajama sets, shoes, shirts, and pants, were communicated to the facility, but no response was provided. The facility's grievance log did not document any grievance related to the missing clothing, and the resident's electronic medical record lacked an inventory list of personal items. Despite requests, the facility was unable to provide documentation of the inventory for the resident in question. Facility policy requires that all resident personal items be inventoried at admission, with documentation retained in the medical record, and that inventories be reviewed and signed off at discharge. Additionally, the grievance policy mandates that grievances be tracked, investigated, and concluded with a written decision. In this case, these procedures were not followed, as evidenced by the absence of inventory documentation and the lack of a recorded or investigated grievance regarding the missing items.
Failure to Ensure CPR Training, Certification, and Emergency Supplies
Penalty
Summary
The facility failed to ensure that nursing staff possessed the necessary skills and training to perform CPR, as well as to maintain a process for identifying and tracking staff CPR certifications. Two residents, both identified as full code with active physician orders for resuscitation, experienced cardiac arrest events in the facility. During these emergencies, staff were unable to provide high-quality CPR due to missing essential supplies, such as Ambu bags and protective barriers, on the crash cart. Staff interviews revealed that some nurses were not CPR certified, had not been offered training, and did not know who was responsible for checking or stocking the crash cart. In both incidents, the crash cart was not easily accessible, and staff had to search for necessary respiratory supplies during the code events, resulting in delays in care. The crash cart was found to be located in a difficult-to-access area, sometimes blocked by other equipment, and was not routinely checked or restocked. Staff reported that there was no designated person responsible for ordering or stocking emergency supplies, and requests for additional supplies were not fulfilled in a timely manner. Documentation showed that Ambu bags were ordered only after the first code event, and supplies did not arrive before the second code event occurred. The facility's policies stated that staff would maintain current CPR certification and that crash carts would be routinely checked and stocked with critical supplies. However, interviews and record reviews indicated that these policies were not followed. Staff were unclear about their responsibilities regarding emergency preparedness, and there was no system in place to ensure that staff were trained or that crash carts were properly maintained. The facility assessment also failed to identify the need for emergency respiratory supplies.
Failure to Ensure Readily Available Respiratory Supplies During Emergencies
Penalty
Summary
The facility failed to ensure that proper respiratory supplies were readily available and accessible during emergencies, resulting in delays in care for two residents. Observations revealed that crash carts were not easily accessible, with one cart wedged between a treatment cart and a wall, and another blocked by equipment in a utility room. Staff interviews confirmed that essential supplies such as Ambu bags and barriers were missing from the crash carts during code situations. Multiple staff members reported having to leave the resident's room to search for necessary respiratory equipment, causing further delays in providing life-saving interventions. Staff members consistently stated they did not know who was responsible for checking or stocking the crash carts, and there was no documentation of regular crash cart checks or supply inventories. During at least two separate code events, staff were unable to immediately locate Ambu bags or respiratory barriers, and in one instance, a staff member had to use a personal barrier due to the lack of available supplies. The lack of clear responsibility and oversight for maintaining emergency equipment contributed to the deficiency. A review of the facility's assessment and policies showed that respiratory care and services, including the Pulmonary Program, were not adequately addressed. The assessment did not include information on the types of respiratory care provided, changes in staffing, equipment needs, or staff training and competencies related to respiratory care. Additionally, the medical supplies section failed to address emergency respiratory supplies such as Ambu bags, CPAP, or BIPAP equipment, further indicating gaps in preparedness for respiratory emergencies.
Facility Assessment Not Updated for Pulmonary Program Implementation
Penalty
Summary
The facility failed to review and update its Facility Assessment when a new pulmonary program was planned and implemented. The assessment, dated 1/7/25, did not include any information regarding respiratory care and services, the addition of a pulmonary program, changes in staffing related to the program, necessary equipment for participating residents, staff training or competencies for the program, or medical supplies such as CPAP, BIPAP, or emergency respiratory supplies like Ambu bags. This omission was identified through record review and interviews with staff, who confirmed the pulmonary program had been in place for about a year and that respiratory therapists had recently started working in the facility. Staff interviews revealed that the administrator was unsure why the pulmonary program was not included in the facility assessment, despite being in the position when the program was implemented. Another staff member described the ongoing development of the respiratory program, including recruitment of respiratory therapists and the program's intended benefits for residents. However, this staff member was not involved in the facility assessment process. The lack of updates to the facility assessment increased the risk for negative outcomes for residents requiring pulmonary care, and a negative outcome did occur, as cited in other deficient practice areas.
Failure to Provide Effective Staff Training on Supplies, Crash Cart, and CPR
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for new and existing staff, including contracted staff, as evidenced by multiple staff interviews and record reviews. Several staff members reported not receiving training on the location of supplies, supply ordering procedures, the contents and management of the crash cart, and CPR certification. Staff members indicated they were not shown where supplies were kept, how to order them, or how to document supply needs. In emergency situations, staff were unable to quickly locate necessary equipment such as Ambu bags, and there was confusion regarding the stocking and checking of the crash cart. Some staff had not received CPR training or certification during their employment, and there was no clear documentation or policy outlining these training requirements. The facility's employee handbook provided only general statements about orientation and in-service training, without specific guidance or policies related to the identified deficiencies. Staff interviews revealed a lack of designated responsibility for stocking supplies and the crash cart, and inconsistent knowledge among staff about procedures for ensuring supplies and emergency equipment were available and properly maintained. The absence of a structured and documented training program contributed to staff being unprepared to perform essential duties, particularly in emergency situations.
Failure to Train Staff on Infection Prevention and Control Program
Penalty
Summary
The facility failed to ensure that new staff, existing staff, and contracted staff received training on the infection prevention and control program, including written standards, policies, and procedures. Multiple staff members, including newly hired and contracted personnel, reported during interviews that they had not received any education on infection prevention or hand hygiene policies and procedures. Additionally, these staff members were unaware of the identity of the Infection Preventionist. Further interviews revealed that the facility had not had an Infection Preventionist since the end of November 2024, and the new Infection Preventionist only started on January 21, 2025. Review of the facility's Infection Prevention and Control Program document indicated that all staff were required to receive training relevant to their roles, but this was not being implemented as described.
Failure to Follow Physician Orders and Medication Administration Parameters
Penalty
Summary
The facility failed to adhere to professional standards of practice by administering medications contrary to physician orders for three residents. For one resident, Midodrine was given 20 times despite blood pressure readings outside the ordered parameters, which specified the medication should be held if systolic blood pressure exceeded 120 or diastolic exceeded 60, and the provider should be notified if the medication was held. Another resident received Midodrine 13 times when their blood pressure was outside the prescribed limits. In both cases, staff interviews confirmed that vital signs should be checked immediately prior to administration and that medications with parameters should not be given if those parameters are not met. A third resident was administered Atenolol 15 times without documentation of blood pressure or pulse prior to administration, despite orders to hold the medication if blood pressure was below 100/60 or heart rate below 60. Staff interviews revealed a lack of adherence to the requirement to obtain and record vital signs before administering medications with specific parameters. Facility policy also required that medications be administered according to physician orders and professional standards, including obtaining and recording vital signs when applicable.
Failure to Follow Physician-Ordered Medication Parameters
Penalty
Summary
The facility failed to properly administer medications according to physician-ordered parameters for three residents. For one resident with orthostatic hypertension, Midodrine HCL was administered multiple times when blood pressure readings were outside the specified parameters, contrary to the physician's order to hold the medication if systolic blood pressure exceeded 120 or diastolic exceeded 60. Another resident with hypotension also received Midodrine HCL on several occasions when blood pressure readings were above the ordered hold parameters. In both cases, the medication was given despite documented blood pressure readings that should have resulted in the medication being withheld. Additionally, a third resident prescribed Atenolol for essential hypertension received the medication on numerous occasions without any documentation of blood pressure or pulse prior to administration, despite orders to hold the medication if blood pressure was below 100/60 or heart rate below 60. Interviews with multiple staff members confirmed that vital signs should be checked immediately before administering medications with such parameters, and that this practice is part of the standard medication administration protocol. Facility policy also requires adherence to the six rights of medication administration, including proper documentation.
Failure to Adhere to Infection Control and Hand Hygiene Practices
Penalty
Summary
Facility staff failed to adhere to infection prevention and control practices, specifically regarding hand hygiene and the implementation of enhanced barrier precautions. Multiple staff members were observed not performing hand hygiene before or after resident contact, after touching potentially contaminated surfaces, or when moving between resident rooms. For example, one staff member handled medication cups and a computer before administering medications to a resident without performing hand hygiene, while another staff member entered and exited several resident rooms, handled meal trays, and assisted with meals without washing hands or using sanitizer. Staff members also demonstrated a lack of awareness and training regarding infection prevention protocols. Several staff could not recall the last time they received infection prevention or hand hygiene training, and some were unaware of which residents required enhanced barrier precautions. In one instance, a staff member was not aware that a resident with a suprapubic catheter and tube feeding should have been on enhanced barrier precautions, and there was no signage or personal protective equipment available for that resident. The facility had a lapse in infection prevention oversight, as the previous Infection Preventionist had resigned and there was a gap before a new person assumed the role. During this period, monitoring and education on infection control practices were not consistently provided. Review of facility documents showed that only a limited number of staff had attended recent infection control in-services, and the infection control policy required hand hygiene and proper use of enhanced barrier precautions, which were not being followed in practice.
Failure to Provide Proper Foley Catheter Care and Documentation
Penalty
Summary
The facility failed to provide proper daily indwelling Foley catheter care to two residents, resulting in resident discomfort and the presence of foul urine odors. Observations revealed that both residents had indwelling Foley catheters with red penile meatus and a crusty, solid-like material near the catheter insertion site. One resident reported pain at the catheter site, while the other stated that it had been a couple of days since anyone had performed peri-care or cleaned the catheter. Both residents' rooms had strong urine odors, and staff interviews confirmed that catheter care was not consistently performed as required. Further review showed that documentation of catheter care was lacking, with one resident's catheter care not recorded in the medication administration record due to a missing physician order. Staff interviews indicated that while catheter care was supposed to be performed every shift and documented, there was a reliance on CNAs to complete the care without consistent verification by nursing staff. The facility's policy required catheter care every shift, but this was not followed, leading to the observed deficiencies.
Deficiencies in Staff Role Clarity and Resident Care Follow-Up
Penalty
Summary
The facility failed to ensure that staff members' job duties were current and accurately reflected their scope of practice. Specifically, a social services note in a resident's chart indicated that a staff member was involved in care planning and medication dispensing, which was outside their job description. Interviews revealed that the staff member did not have the authority to hire or fire staff, orient new employees, or provide leadership training, despite these responsibilities being listed in their job duties. Additionally, there was a lack of completed performance evaluations and competency assessments for the staff member. The facility also failed to ensure that staff members were practicing within their scope of practice. A staff member admitted to assessing residents and recommending psychotropic medications, which was not within their professional scope. Another staff member, without a clinical background, was involved in assessing behavioral health concerns and recommending medications, which was inappropriate. This was evidenced by a social services note recommending antidepressants and anxiety medications for a resident, despite the staff member's lack of clinical qualifications. Furthermore, the facility did not adequately follow up on residents who left against medical advice (AMA). A resident who left AMA reported feeling unsafe and expressed dissatisfaction with the facility's care, yet there was no follow-up from the facility. The facility had 21 AMA discharges within a specified period, indicating a potential pattern of inadequate care or communication. Additionally, there were issues with documenting behavioral health concerns, as staff often did not record behaviors they did not witness, and there was a lack of enforcement of policies against substance use, which could exacerbate residents' conditions.
Inadequate Documentation and Communication in AMA Discharges
Penalty
Summary
The facility failed to properly document and communicate the circumstances surrounding the discharge against medical advice (AMA) for two residents, identified as #4 and #12. For resident #4, there was no nursing documentation completed, and the resident's wishes, preferences, or requests were not included in the documentation. Additionally, Adult Protective Services (APS) was not contacted. The resident expressed confusion and dissatisfaction with the facility, stating that they were not informed of their rights or offered transportation upon discharge. The resident's electronic health record (EHR) contained conflicting information about their orientation and anticipated stay at the facility. Resident #12's situation involved a lack of advance notification to the resident's caregiver about the discharge, and similar to resident #4, there was no nursing documentation or inclusion of the resident's wishes in the records. The resident required multiple cares, including wound care and antibiotics, and was initially told they would be discharged on a specific date. However, the discharge was postponed without clear communication, leading to the resident's frustration and desire to leave AMA. Interviews with staff members revealed inconsistencies in the facility's handling of AMA discharges, with some staff members acknowledging a lack of documentation and communication. Staff member F admitted to not contacting the ombudsman regarding resident #4's AMA discharge. The facility's policy on AMA discharges emphasized the importance of informing residents and their representatives of the risks and benefits, documenting discussions, and notifying appropriate entities if self-neglect is suspected, but these procedures were not followed in the cases of residents #4 and #12.
Failure to Complete Timely MDS Assessments
Penalty
Summary
The facility failed to complete required MDS assessments for several residents, leading to overdue assessments. Specifically, Quarterly MDS Assessments were not completed for four residents, with delays ranging from 44 to 61 days. An Annual MDS Assessment for one resident was 10 days overdue, and a Discharge MDS for another resident was 48 days overdue. The MDS coordinators, who were new to their roles, admitted to being behind on completing MDS assessments and were unsure of the specific timelines required for completion. Interviews with staff revealed a lack of oversight and consistent nursing administration, contributing to the delays. The MDS coordinators were inexperienced, having only recently started their roles, and had not previously completed MDS assessments. Despite some educational efforts by other staff members, the facility's policy on MDS completion was not adhered to, resulting in the overdue assessments. The responsibility for ensuring timely and accurate completion of MDS assessments ultimately fell to a staff member who acknowledged the oversight failure.
Failure to Timely Submit MDS Information
Penalty
Summary
The facility failed to submit Minimum Data Set (MDS) information within 14 days of completion for five of the fifteen sampled residents. Staff interviews revealed that the MDS assessments were late due to the inexperience of the two new MDS coordinators and a lack of consistent oversight in the building. Specifically, the Quarterly MDS for residents with Assessment Reference Dates (ARD) ranging from early September to late October were overdue by 44 to 61 days. Additionally, an Annual MDS and a Discharge MDS were also overdue by 10 and 48 days, respectively. The facility's policy requires all assessments to be transmitted to the designated CMS system within 14 days of completion, which was not adhered to in these cases.
Failure to Address High AMA Discharges
Penalty
Summary
The facility's quality assurance and performance improvement committee failed to identify and address concerns regarding a high number of residents discharging against medical advice (AMA) over the past year. Specifically, 21 residents left the facility AMA without physician discharge approval or a completed plan of care, putting them at risk for negative outcomes. One resident, who left the facility after less than 24 hours, reported feeling unsafe, encountering rude staff, and experiencing poor food quality. This resident expressed concerns about the facility's duty of care and noted that no follow-up occurred after their AMA discharge. The facility's records confirmed the 21 AMA discharges from January 2024 to the current date.
Non-Compliance with Smoking Policy and Resident Safety
Penalty
Summary
The facility failed to ensure compliance with its smoking policy, resulting in several deficiencies. One resident was observed smoking only a few feet away from the activities room door, allowing cigarette smoke to enter the facility, contrary to the policy requiring smoking to occur at least 25 feet from exits and common spaces. Additionally, a resident was found with personal tobacco in their room, indicating that smoking materials were not stored in the designated secure location as required by the facility's policy. Furthermore, the facility did not adequately assess the cognitive abilities of residents to determine their need for supervision while smoking. Two residents with low Brief Interview for Mental Status (BIMS) scores, indicating severe cognitive impairment, were listed as not needing supervision while smoking. This oversight suggests a failure to properly evaluate and document the residents' ability to safely smoke independently, as outlined in the facility's smoking policy.
Failure to Inform Residents of Psychotropic Medication Risks and Benefits
Penalty
Summary
The facility failed to ensure that residents or their representatives were fully informed and understood the risks and benefits of psychotropic medications. Specifically, two residents, identified as #6 and #9, were not provided with adequate information regarding their medications. Resident #6 expressed that he was unaware of the names, side effects, or benefits of the medications he was taking for his mood, and stated that no one had provided him with this information. Similarly, resident #9, who manages her own medical and financial decisions, reported taking medications for anxiety and depression without being informed of their side effects. Both residents' psychotropic consent forms lacked signatures from the residents or their representatives, indicating that the risks and benefits were not reviewed or understood. Staff member F, who completed the psychotropic consent forms, was unable to confirm whether the risks and benefits were discussed with the residents or their representatives. Furthermore, staff member F admitted to not having a clinical background and could not articulate the risks or benefits of psychotropic medication use. The facility's policy on the use of psychotropic medications, revised in June 2024, mandates that residents and/or their representatives be educated on the risks and benefits of such drug use, as well as alternative treatments. However, this policy was not adhered to in the cases of residents #6 and #9.
Inaccurate MDS Assessments for Diagnoses and Medications
Penalty
Summary
The facility failed to ensure accurate coding of MDS assessments for two residents regarding their diagnoses and psychotropic medication use. For one resident, a physician's progress note indicated diagnoses of anxiety and depression, but the Quarterly MDS did not reflect these diagnoses in the relevant sections. Additionally, the MDS failed to document the administration of antipsychotic medication, despite records showing the use of high-risk drug classes, including antipsychotics, antianxiety, and antidepressants during the look-back period. For another resident, the MDS did not mark any psychiatric or mood diagnoses, even though the resident was taking antipsychotic and antidepressant medications. The MDS inaccurately indicated that no antipsychotic medication was given. Interviews with staff members revealed a lack of awareness regarding these inaccuracies. The facility's policy on MDS completion requires staff to attest to the accuracy of the sections they complete, which was not adhered to in these cases.
Inadequate Discharge Planning and Communication
Penalty
Summary
The facility failed to provide an appropriate discharge plan for a resident, resulting in insufficient and incomplete documentation throughout the discharge planning process. Interviews with staff and review of the resident's electronic health record (EHR) revealed that the resident's caregiver was not notified of the discharge in advance, and there was no nursing documentation of the discharge. Additionally, the documentation lacked any statements, wishes, requests, preferences, or treatment goals for the resident. Staff member C expressed concerns about the discharge plan not being executed as communicated by social services, and NF5, another staff member, indicated confusion and lack of communication regarding the resident's discharge appropriateness due to medical acuity. The resident, who required daily wound care, antibiotics, and the removal of a central line catheter, was initially informed by staff member F about the discharge plan on November 5th, with an agreed discharge date of November 20th. However, on November 19th, the resident was informed that the discharge could no longer proceed as planned, leading to the resident's frustration and consideration of leaving against medical advice (AMA). Staff member A acknowledged that the discharge process required significant improvement, highlighting the facility's failure to adequately plan and communicate the discharge process to the resident and involved parties.
Failure to Provide Behavioral Health Services
Penalty
Summary
The facility failed to identify and document DSM diagnoses on the Resident Matrix and did not consistently document behaviors or offer behavioral health services to residents with a DSM diagnosis. Specifically, for one resident with anxiety disorder and major depressive disorder, the facility did not provide necessary behavioral health services. The resident's electronic health record (EHR) showed the last psychological evaluation was conducted over three years ago, and no behavioral health services were offered during the resident's stay, despite the resident experiencing anxiety and agitation. Interviews with staff revealed a lack of documentation and follow-up on behavioral health issues. Staff member C admitted to not documenting behaviors unless they were directly observed and expressed frustration that concerns about residents' behaviors, such as substance use, were not addressed by the facility's leadership. Staff member E indicated that while they could assess patients, they deferred to another staff member for psychotropic medication recommendations, despite the latter not having a clinical background. The facility's policy on behavioral health services stated that all residents should receive necessary services to maintain their highest level of mental and psychosocial functioning. However, the facility did not track behavioral health appointments, and staff training on behavioral health was deemed insufficient. The facility's assessment document indicated a need for behavior management and collaboration with mental health professionals, but these services were not adequately provided or documented for the resident in question.
Inadequate Wound Care and Documentation
Penalty
Summary
The facility failed to provide adequate wound care for a resident who required a wound vac for a pressure ulcer. The resident reported that the wound vac care was incorrect, and the device was only functional for a week. Staff instructed the resident to sit on the wound vac to seal the suction when it alarmed, which was not an appropriate intervention. The resident's condition worsened, leading her to leave the facility against medical advice. Interviews and record reviews revealed that staff member F, who was trained on wound care, was responsible for the resident's wound vac management. However, there was a lack of documentation regarding the difficulties with the wound vac, such as maintaining a seal, drainage amounts, and reasons for removing the wound vac. Staff member F admitted to not documenting these issues and believed the canister was changed only when full. Additionally, staff member B noted that the wound nurse was on maternity leave, and staff member F was having trouble with documentation and would change orders without proper documentation. The resident's medical records showed multiple physician orders for wound vac management, but there was no documentation of the resident's noncompliance or frequent dressing changes. The facility's policy required wound assessments and documentation of treatments, but these were not consistently followed. The resident's wound was noted to be deteriorating, with increased depth and surface area, and the facility failed to document the necessary interventions and modifications to the treatment plan.
Incomplete Investigations of Abuse and Neglect Allegations
Penalty
Summary
The facility failed to provide evidence of thorough investigations for allegations of abuse involving five residents. In one instance, a CNA allegedly forced a resident to drink water, but the investigation lacked details such as the identity of the alleged abuser, the person making the allegations, and any protective interventions during the investigation. The documentation was incomplete, missing interviews with staff or residents, and did not specify who conducted the investigation. In another case, a resident complained of verbal assault by a nurse who played loud music while dispensing medication. The investigation confirmed the nurse's behavior, but the documentation did not include the full name of the accused nurse, interviews with the accused, or protective measures for the resident. The investigation was incomplete, lacking details on who conducted it and whether the abuse allegation was substantiated. Additionally, a resident alleged neglect of care when a CNA failed to provide necessary services, resulting in a leaked foley bag. The investigation confirmed the neglect, but documentation was missing key details such as the identity of the alleged abuser, interviews, and care plan interventions. An altercation between two residents also lacked a thorough investigation, with missing interviews and protective measures. The facility's policy on abuse, neglect, and exploitation was not followed, and documentation was incomplete due to the absence of the social services director responsible for investigations.
Failure to Timely Report Allegations of Abuse
Penalty
Summary
The facility failed to report allegations of abuse within the required 24-hour timeframe for two residents. In the first incident, a resident complained of being verbally assaulted by a nurse who was playing music on a personal device while dispensing medication. This incident, witnessed by other staff members, occurred on June 8, 2024, but was not reported to the State Survey Agency until June 10, 2024. In the second incident, a resident was involved in a verbal altercation with a staff member, leading to police involvement. This incident occurred on September 1, 2024, but was not reported until September 4, 2024. During an interview, a staff member indicated that she was not informed of the second incident until she returned from vacation on September 4, 2024. The facility's policy requires immediate notification to appropriate agencies, no later than 24 hours after discovery of the incident, or within 2 hours in cases of serious bodily injury.
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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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