Wibaux County Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Wibaux, Montana.
- Location
- 712 Wibaux St S, Wibaux, Montana 59353
- CMS Provider Number
- 275079
- Inspections on file
- 23
- Latest survey
- April 9, 2026
- Citations (last 12 mo.)
- 7 (1 serious)
Citation history
Health deficiencies cited at Wibaux County Nursing Home during CMS and state inspections, most recent first.
The facility failed to timely report several allegations of abuse and neglect to the administrator and State Survey Agency as required by its policy. In one case, a resident experienced inadequate hygiene care and lack of monitoring after vomiting, identified later on video, but the allegation was not promptly reported. In another incident, a staff member’s physical contact caused a resident to lose balance and be assisted to the floor, and both the involved staff and a witness delayed notifying the nurse. In a third situation, a staff member allegedly verbally abused two residents by threatening a cold shower and ordering a resident to sit down and be quiet, and the witnessing staff member did not report these events until days later, resulting in late external reporting.
A resident with a history of aggressive behaviors experienced repeated episodes of emesis while seated in a recliner and remained in vomit-soiled conditions for an extended period. Camera review showed that, despite periodic checks and signs of restlessness and coughing, staff did not provide timely hygiene care, did not perform or document a physical assessment, and did not increase monitoring, aside from placing a towel and changing the resident’s shirt shortly before shift change. Nursing notes lacked documentation of assessment or interventions related to the emesis episodes, and the resident continued to exhibit verbal and physical aggression during later care attempts.
A staff member transferred a resident alone using a mechanical lift, contrary to the care plan requiring two staff, resulting in the resident falling and sustaining fatal injuries. Staff interviews revealed that single-person transfers with mechanical lifts were a common practice, and that staff had not received proper training or orientation on lift use. The incident was cited as an Immediate Jeopardy deficiency for failure to prevent accident hazards.
A resident who was fully dependent on staff for transfers was moved using a mechanical lift by only one staff member, contrary to the care plan and standard safe lifting practices. This occurred after the facility reduced staffing levels, leading to a fall that caused severe injuries, including a subdural hematoma and cervical fracture. The resident died three days later as a result of these injuries.
The facility did not ensure that nurses and CNAs received proper training or competency evaluation on mechanical lift procedures, with only one staff member having documented training. Staff reported a lack of formal instruction and were advised by peers to perform lift transfers independently. This deficiency was identified after a resident fell from a mechanical lift and sustained major injuries.
A resident who required total assistance for transfers was injured after falling from a Hoyer lift operated by a single CNA, despite the care plan requiring two staff. Staff interviews revealed that single-person mechanical lift transfers were a common and known practice due to reduced staffing levels, with management aware that policy was not being followed.
A resident who required total assistance for transfers was moved using a mechanical lift by only one staff member, contrary to the care plan and professional standards. Multiple staff confirmed they were trained to use two people for such transfers but sometimes worked alone due to staffing shortages, resulting in single-person use of the lift.
The facility did not ensure that the dietary manager had completed the required certification or higher education for the position. During observations and staff interviews, it was confirmed that the dietary manager was only partway through an online certification program and had not yet met the qualifications, an issue that had persisted since the last survey.
Two residents with cognitive impairment experienced multiple elopement incidents due to the facility's failure to timely identify risks, implement effective interventions, and ensure staff awareness. Window security was inadequate, elopement assessments were delayed, and staff did not consistently follow care plan interventions or recognize elopement events, resulting in ongoing hazards and insufficient supervision.
Surveyors found that several residents had incomplete or altered medical records, including missing signatures and dates on POLST forms, delayed completion of elopement assessments, and care plans containing irrelevant personal information about staff. Staff interviews confirmed that some documentation was intentionally altered or delayed, and facility policies on proper documentation were not consistently followed.
A resident with multiple mental health diagnoses and recent changes in psychotropic medications due to behavioral symptoms was not referred for a required Level II PASRR review. The staff member responsible did not complete the necessary Level I screening in a timely manner, and a completed Level I was not available during the survey.
The facility did not consistently develop and implement baseline care plans within 48 hours of admission for several residents. Staff interviews and record reviews showed that immediate care needs, such as fall risk, elopement risk, and psychotropic medication monitoring, were not promptly addressed in the care plans, leading to gaps in care planning for new admissions.
Two residents did not have individualized, comprehensive care plans addressing their specific needs. One resident's care plan lacked interventions for elopement risk and did not note their placement on a secure unit. Another resident's care plan failed to address her frequent crying, did not specify her activity preferences, and omitted guidance for staff regarding family attempts to remove her against medical advice.
Two residents did not receive individualized or meaningful activities, with one resident repeatedly pacing and attempting to exit the secured unit without staff engagement, and another resident left unengaged during a group activity. Staff did not follow care plan interventions or incorporate resident preferences into activity planning, and CNAs were often solely responsible for both monitoring and activities, leading to insufficient attention to residents' interests.
Two residents with severe cognitive impairment and on psychotropic medications were provided with bed grab bars without thorough assessment or documentation of risks and benefits. Staff did not attempt alternative interventions, failed to consider entrapment hazards, and did not document the impact of medications or resident conditions on safety. Required safety reviews and maintenance checks were also not completed.
A resident with severe cognitive impairment eloped from the facility and was absent for 12 hours, during which they stayed in a stranger's cabin overnight. The facility failed to inform the resident's family and provider about these details, preventing necessary medical evaluations. Staff acknowledged the expectation to report such events to the provider and family.
A resident with severe cognitive impairment eloped from the facility and spent the night at a stranger's cabin. Upon return, the facility failed to conduct a comprehensive physical or sexual assault assessment, contrary to their post-elopement procedures. Staff were unaware of the full details of the incident and did not follow the policy to ensure the resident's safety.
A cognitively impaired resident with a history of elopement attempts left the facility unsupervised overnight due to broken door alarms and inadequate monitoring. The resident exited through a memory unit door and a gate, both of which failed to alarm. Staff were aware of the broken alarms but did not implement effective measures to prevent the elopement. The resident was later found at an RV park across the road.
Failure to Timely Report Allegations of Abuse and Neglect
Penalty
Summary
The deficiency involves the facility’s failure to timely report multiple allegations of abuse and neglect to the State Survey Agency and to the administrator as required by its Abuse, Neglect, and Exploitation policy. For one resident, an event involving lack of hygiene care and lack of monitoring after episodes of vomiting occurred during a night shift and was identified the following morning through review of video surveillance. Although the facility recognized the concern on that date, the allegation was not reported to the State Survey Agency until several days later, and staff acknowledged they did not realize it should have been reported at the time. In a separate incident, a staff member providing care to a resident made physical contact with the resident’s shoulder, causing the resident to lose balance and be assisted to the ground; the staff member did not report this event to the nurse because she did not believe it was reportable. Another staff member who witnessed the event also delayed reporting it to the nurse until the following day. In an additional event, a staff member allegedly verbally abused two residents by making a remark about giving one resident a cold shower to “cool” them off and telling another resident to sit down and be quiet. The witnessing staff member did not report these verbal abuse allegations to the nurse until two days later. These delays in internal reporting resulted in the facility failing to notify the State Survey Agency within the required 2-hour or 24-hour timeframes outlined in its written procedures.
Failure to Provide Hygiene Care and Assessment After Repeated Emesis
Penalty
Summary
The facility failed to provide necessary care and services to maintain a resident's quality of life, personal dignity, comfort, and safety when a resident experienced multiple episodes of vomiting while seated in a recliner. Camera footage documentation showed the resident vomited at 6:45 p.m. and 7:51 p.m., with no hygiene care provided following these episodes. The resident remained in vomit-soiled conditions, and although staff periodically checked on her throughout the early evening, she was noted to be restless and coughing until 8:48 p.m., with no further check by NF8 until 10:51 p.m. The only interventions documented were the placement of a towel and a shirt change shortly before shift change, and there was no evidence of a physical assessment, monitoring, or other interventions in response to the vomiting episodes. The resident had a documented history of aggressive behaviors and language in nursing progress notes from 2/1/26 to 3/31/26, which at times made it difficult for staff to provide care. On 4/8/26 at 7:35 a.m., the resident was observed with no skin breakdown, kept her eyes closed, and was verbally and physically aggressive to staff during repositioning for skin observation. Nursing progress notes dated 3/18/26 at 2:30 a.m. showed no documentation of physical assessment or increased monitoring following the vomiting episodes. Staff member A reported that NF8 and NF9, who were travel staff, had been assigned to the resident on the night shift when the vomiting occurred, and that video surveillance was reviewed after concerns were identified and reported the following morning.
Failure to Ensure Safe Mechanical Lift Transfers Resulting in Resident Death
Penalty
Summary
A facility staff member failed to properly transfer a resident using a mechanical lift, resulting in a fall that caused significant injuries and ultimately contributed to the resident's death. The resident required total assistance for transfers, as documented in the care plan, which specified the use of a Hoyer lift with two staff members present. Despite this, the staff member performed the transfer alone, and during the process, one of the sling straps became unhooked, causing the resident to fall to the floor. The resident sustained a subdural hematoma, a C2 cervical fracture, and a forehead laceration, and passed away three days later, with the fall listed as a contributing factor on the death certificate. Interviews and record reviews revealed that the staff member who performed the transfer had not received orientation or a return demonstration on the use of mechanical lifts. She reported that it was common practice at the facility for CNAs to use the lifts alone, and that new staff were trained to do so. Other staff members corroborated that using mechanical lifts without a second person was a routine practice, and that straps had previously come unhooked during transfers. The staff member acknowledged knowing that two people were required for safe use of the lift but did not follow this protocol at the time of the incident. Additional staff interviews confirmed that the improper use of the mechanical lift was a known issue, with some staff reporting that they had observed or participated in single-person transfers despite the care plan and facility policy requiring two staff members. The incident was identified as an Immediate Jeopardy situation due to the risk of serious harm, and the deficiency was cited under F689 for failure to ensure the environment was free from accident hazards and that adequate supervision was provided to prevent accidents.
Failure to Follow Safe Mechanical Lift Practices Resulting in Resident Death
Penalty
Summary
Facility staff failed to protect a resident from neglect by not following safe lifting practices during transfers with a mechanical lift. Multiple staff interviews revealed that, despite being trained to use two staff members for mechanical lifts, the facility had adopted a practice of using only one staff member for these transfers. This change was attributed to reduced staffing levels following administrative decisions to decrease staff hours. The resident's care plan specifically required two staff members to assist with transfers using a Hoyer lift, but this directive was not followed. As a result of this failure, the resident, who was totally dependent on staff for transfers, fell from the Hoyer lift. The incident resulted in the resident being found on the floor with significant injuries, including a subdural hematoma, C2 cervical fracture, and a forehead laceration. The resident was transported to the hospital and died three days later. The cause of death was listed as a subdural hematoma due to a fall from a Hoyer lift.
Failure to Ensure Staff Competency in Mechanical Lift Use
Penalty
Summary
The facility failed to ensure that licensed nurses and certified nurse assistants received proper training and competency evaluation on the procedure and safety requirements for using mechanical lifts. Fifteen out of sixteen sampled staff members had not received this training, and documentation of mechanical lift competency was only available for one staff member. New staff reported that they did not receive any training from the Director of Nursing prior to working with residents and were instead oriented by other CNAs, who advised that mechanical lift transfers could be performed independently, contrary to standard safety protocols. Several staff members confirmed they had not completed mechanical lift competency evaluations prior to a resident fall incident, with some stating their last training was years ago during their initial certification. A review of records showed that only one staff member had documented mechanical lift training, and the facility could not provide evidence of training for the remaining licensed and certified nursing staff, including management staff with CNA certification. The deficiency was highlighted by an incident in which a resident fell from a mechanical lift, resulting in the resident being found on the floor with significant bleeding. The incident was staff-witnessed, and it was reported that the transfer was performed using a mechanical lift.
Failure to Ensure Safe Mechanical Lift Transfers Due to Inadequate Staffing
Penalty
Summary
The facility failed to administer care in a manner that ensured individualized and safe transfer procedures for a resident requiring total assistance. The resident's care plan specified the use of a Hoyer lift with two staff members for transfers but did not identify the appropriate sling size. On the date of the incident, the resident was found on the floor with significant bleeding after falling from a Hoyer lift. Documentation and interviews revealed that the transfer was performed by a single certified nurse assistant, contrary to the care plan and facility policy. Multiple staff interviews confirmed that it was common practice for certified nurse assistants to operate mechanical lifts independently, and that management was aware of this deviation from policy. Staff reported that this practice had been ongoing for over a year, largely due to reduced staffing levels following administrative decisions to decrease staff hours. The reduction in available staff made it difficult to consistently have two staff members present for mechanical lift transfers, directly contributing to the incident.
Failure to Follow Two-Person Mechanical Lift Protocol Due to Staffing Shortages
Penalty
Summary
The facility failed to ensure that services were provided according to professional standards regarding the safe use of mechanical lifts for one of eight sampled residents. The resident's care plan specified total dependence on two staff members for transfers using a Hoyer full body mechanical lift. Interviews with staff revealed that, despite being trained to use two staff for mechanical lifts, staff members sometimes performed transfers alone due to staffing shortages. Staff acknowledged awareness of the requirement for two-person assistance but reported that single-person transfers occurred when only one CNA was available per hall, and that this practice was not consistent with their training or facility policy.
Dietary Manager Lacks Required Certification
Penalty
Summary
The facility failed to ensure that the dietary manager had completed a certification program approved by a national certifying body or possessed higher education in a related field, as required for the role. During a kitchen tour, no documentation of advanced training for the dietary manager was observed. Interviews with staff revealed that the dietary manager had not yet obtained certification and was only in the early stages of an online Certified Dietary Manager/Certified Food Protection Professional program, with no clear completion date identified. This issue had been ongoing since the previous survey, and the facility's own assessment acknowledged that the dietary manager was still working toward certification.
Failure to Identify and Prevent Elopement Risks on Secure Unit
Penalty
Summary
The facility failed to timely identify and address elopement risks for two residents living on the secure unit, resulting in multiple incidents where residents left the premises or a safe area without proper supervision. One resident with severe cognitive impairment experienced three separate elopements by climbing out of unsecured or inadequately secured windows. The facility did not complete elopement assessments until after all three incidents had occurred, and the baseline care plan did not initially identify elopement as a problem or include interventions to prevent it. Interventions such as window audits and monitoring devices were either ineffective or not implemented in a timely manner, and staff were not consistently aware of or able to identify elopement events. Staff interviews revealed a lack of understanding regarding what constitutes an elopement, with some staff not recognizing that a resident leaving through a window into a courtyard or other area without supervision was an elopement. Documentation was incomplete, with no nursing notes for some elopement events, and required post-elopement assessments and social services follow-up were not performed as outlined in facility policy. Observations showed that window security devices were either improperly installed, easily removed by residents, or not yet installed on all windows, leaving ongoing elopement hazards present in the secure unit. Another resident identified as at risk for elopement did not have this risk included in the baseline care plan, and interventions were minimal and not consistently implemented by staff. Observations showed this resident repeatedly attempting to exit the secure unit and interacting with unsecured windows, with staff failing to redirect or engage the resident as required by the care plan. The overall elopement prevention system was inadequate, with insufficient supervision, incomplete assessments, and a lack of effective interventions to ensure resident safety.
Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for multiple residents, as evidenced by incomplete, altered, or improperly documented forms. For one resident, a POLST form was found with identifying information obscured by white-out and missing required provider signatures, dates, and phone numbers, rendering the form invalid. The same resident's staff assessment and medication consent forms were also incomplete, with missing dates, signatures, and documentation of consent. Another resident had elopement assessments and evaluations that were not completed until several days after the observation dates, contrary to standard practice, as confirmed by staff interviews. A third resident's elopement evaluation was similarly delayed in completion. Additionally, a POLST form for another resident was left blank in all required provider fields. A review of a care plan for another resident revealed the inclusion of irrelevant and inappropriate information, such as personal references to staff members' spouses, which did not pertain to the resident's care or needs. Staff interviews confirmed that this information was intentionally added to draw attention to the need for care plan updates, rather than for clinical documentation. The facility's policy on confidentiality and documentation was reviewed, but no specific policy regarding POLST forms was provided during the survey.
Failure to Refer Resident for Required Level II PASRR Review
Penalty
Summary
The facility failed to refer a resident with newly evident or possible serious mental disorder or related condition for a Level II review as required. The resident had diagnoses including unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and bipolar disorder, as documented in the care plan and psychiatric progress notes. The psychiatric notes indicated changes in psychotropic medications due to symptoms such as impulsivity and delusions. Despite these changes and the presence of significant mental health diagnoses, staff responsible for coordinating Level I and Level II assessments did not complete a Level I screening for the resident until after the survey began, and a completed Level I was not provided by the end of the survey.
Failure to Develop Timely Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to develop and implement baseline care plans within 48 hours of admission for four residents, as required by policy. Staff interviews revealed that the interdisciplinary team, responsible for care planning, sometimes did not complete baseline care plans on time, especially during busy periods or when multiple admissions occurred. The computer system had a template for care plans, but it was not always utilized promptly. Staff acknowledged awareness of the requirement but admitted that care plans were sometimes delayed or incomplete. Record reviews and observations showed that for several residents, critical care needs were not addressed in the baseline care plans within the required timeframe. For example, one resident's nutrition concerns were not added until several days after admission, another resident's risk for elopement and psychotropic drug interventions were not included promptly, and a third resident's baseline care plan only addressed advance directives and skin risk, omitting other immediate needs. Additionally, a resident with Alzheimer's disease and a high fall risk did not have these risks reflected in the baseline care plan until days after admission, despite assessments indicating the need. These omissions increased the risk of staff not providing necessary care and services due to the lack of timely and comprehensive baseline care plans.
Failure to Individualize and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement individualized, comprehensive care plans for two of sixteen sampled residents. For one resident identified as an elopement risk, the care plan did not specify that the resident lived on a secure unit, nor did it include interventions or approaches to prevent elopement, despite the resident being observed daily in the secured unit. For another resident, the care plan only included a general directive to encourage participation in activities, without identifying the resident's specific interests or addressing her frequent episodes of crying. Staff were unaware of the resident's activity preferences and were observed to be unsure of how to effectively engage her or respond to her emotional distress. Additionally, the care plan for the second resident did not address significant family dynamics, including the potential for family members to remove the resident from the facility against medical advice. Nurse's notes documented an incident where family members attempted to take the resident out of the facility, and the physician instructed staff to contact the police if this occurred. However, the care plan lacked any guidance for staff on how to manage such situations, leaving them without direction in the event of future incidents.
Failure to Provide Individualized and Meaningful Activities for Residents
Penalty
Summary
The facility failed to provide meaningful and individualized activities to meet the preferences and interests of two residents. One resident was repeatedly observed pacing the halls and attempting to exit the secured unit without staff intervention or engagement, despite care plan instructions to redirect, distract, or offer activities, snacks, or conversation. Staff were present but did not attempt to involve the resident in activities or address the resident's behaviors. The resident's care plan only included a general reminder for activities and did not specify the resident's preferences for music, books, or magazines, even though these were noted as somewhat important in the assessment. Another resident was observed sitting passively and not engaged while a staff member painted a car, and other residents at the table were either unresponsive or not participating. Staff interviews revealed that CNAs were responsible for both resident monitoring and activities, often with only one CNA present on the secured unit. Staff admitted to not knowing individual resident preferences and not including individualized activity information in care plans. Activity assessments were limited to standard MDS questions, and staff relied on trial and error to determine resident interests.
Failure to Assess and Document Bed Rail Risks and Benefits
Penalty
Summary
The facility failed to adequately review and document the risks and benefits associated with the use of grab/assist bars attached to the beds for two residents. Observations revealed that one resident had a grab bar on the left side of the bed, while another had grab bars on both sides. Interviews with staff indicated that one resident did not use the side rails during personal care or transfers, and only occasionally used the assist bar when sitting on the edge of the bed. The same resident was noted to have severe cognitive impairment, visual impairments, problems with balance and trunk control, and was taking psychotropic medications, all of which require safety precautions. However, the assessment and consent documentation did not address how the resident's restlessness and other risk factors could impact safety in relation to the grab bars. For the second resident, staff confirmed that the resident requested the side rails be reinstalled after removal, but no alternative interventions were attempted prior to their use. The assessment did not consider entrapment hazards related to the resident's weakness, nor was there evidence of scheduled maintenance or safety measurements for the bed and grab bars. The resident also had severe cognitive impairment and was taking multiple psychotropic medications, but the effects of these medications were not documented as part of the side rail assessment. The facility's failure to thoroughly assess and document the risks and benefits, as well as to consider alternative interventions, led to the deficiency.
Failure to Notify Family and Provider of Elopement Details
Penalty
Summary
The facility failed to notify a resident's provider and family member about the details of an elopement incident involving a resident with severe cognitive impairment, as indicated by a BIMS score of 4. The facility's policy on elopement and wandering residents requires that a nurse perform a physical assessment and report findings to the physician, with any new physician orders communicated to the family or authorized representative. However, in this case, the facility did not inform the resident's family or provider about the 12-hour period during which the resident was absent, including the fact that the resident was taken to a stranger's cabin overnight before being returned to the facility. Interviews with staff and family members revealed that the lack of communication prevented necessary medical evaluations and decisions from being made. Family members and staff stated that had they been informed of the full circumstances, they would have taken additional steps, such as ordering an assault kit and further exams for the resident. The failure to communicate these critical details was acknowledged by staff, who confirmed that it was expected for such events to be reported to both the provider and the family.
Failure to Conduct Comprehensive Assessment Post-Elopement
Penalty
Summary
The facility failed to conduct a comprehensive physical assessment of a resident following an elopement incident, which had the potential for harm related to sexual trauma. The resident, who had a severe cognitive impairment with a BIMS score of 4, was found by a construction worker in his car and was taken to his RV park cabin to sleep. The next morning, the worker realized the resident was confused and returned her to the facility. Upon her return, the resident was not sent for a comprehensive physical or sexual assault examination, despite spending the night at a stranger's cabin. Interviews with staff revealed that there was a lack of communication and adherence to the facility's post-elopement procedures. Staff members were waiting for guidance from the police department and did not follow the policy to send the resident for further examination. The facility's policy required a nurse to perform a physical assessment and report findings to a physician, which was not fully executed. Staff members expressed concerns about the resident's inability to give sexual consent and the absence of a complete physical assessment to rule out sexual assault.
Failure to Secure Memory Unit and Monitor Resident Leads to Elopement
Penalty
Summary
The facility failed to secure the memory unit and adequately monitor a cognitively impaired resident with a known history of elopement attempts. This resulted in the resident leaving the building unsupervised overnight. The incident occurred when the resident exited through the memory lane dining room door, which did not alarm, and then through a fence gate that also failed to alarm. The resident was later found across the road at an RV park, inside someone's cabin, sleeping on a couch. Interviews with staff revealed that the dining room door alarms in the memory unit had been broken for approximately two weeks before the elopement. Staff were aware of the broken door and had attempted to secure it with a temporary childproof lock, which was not effective. The gate alarm required specific steps to activate, and many staff were not trained to set it. The facility's camera footage confirmed that no alarms were heard during the resident's elopement, and no staff were present at the time. The resident involved had a severe cognitive impairment, with a BIMS score of 4, and a history of exit-seeking behavior. The resident's care plan indicated a risk of elopement, with previous incidents of exiting the memory care unit and eloping through a window. The facility's policy on elopements and wandering residents stated that door locks and alarms were in place to prevent such incidents, but these measures were not effectively implemented in this case.
Latest citations in Montana
A dependent resident admitted post-surgery with intact but vulnerable skin and MASD risk developed significant bilateral buttock MASD and a sacral pressure injury that progressed from deep tissue injury to Stage III and then to a large unstageable ulcer with odor and purulent drainage. Facility records showed incomplete and missing weekly skin/wound assessments during the period when the wound worsened, despite a care plan calling for skin evaluations, turning/repositioning, CNA skin inspections, and monitoring of nutrition. Staff interviews revealed they were frustrated by the resident’s anxiety and behaviors, reported the sacral wound as facility-acquired, acknowledged the resident became obtunded on an intense opioid regimen, and stated they were unaware of excessive fluid intake and could not explain why the worsening wound and infection were not recognized or reported before the resident required hospital transfer for a severe sacral decubitus ulcer with associated infection.
Surveyors found that kitchen staff failed to properly label and date multiple food items stored in the walk-in cooler, including slimy sliced tomatoes, ground meat, sliced ham, roast beef, cheese, and strawberries. Staff reported that they sometimes picked moldy strawberries out of shipments and that moldy dinner rolls had been served and then collected from residents. These practices did not follow the facility’s written policy requiring labeling, dating, and monitoring of refrigerated foods so they are used by their use-by date or discarded, placing all residents at risk for foodborne illness.
The facility failed to submit required investigation findings to the State Survey Agency (SSA) within 5 working days for multiple abuse and elopement incidents. In one case, a resident kicked another resident’s feet, and in another, one resident kicked another in the legs while both were in wheelchairs; in both situations, the facility did not provide timely or, in one case, any investigative findings to the SSA. The facility also reported two separate elopement events for a resident but did not submit final investigation reports for either incident. A staff member reported that another staff member, who was absent during the survey, was responsible for SSA reporting, and confirmed the expectation to report all investigation results within 5 working days per facility policy.
Two residents were involved in a resident-to-resident abuse incident in which one resident kicked another multiple times while both were in wheelchairs, and although staff separated them and documented the event, the facility did not complete or document a formal abuse investigation, did not ensure ongoing protection from further confrontations, and did not report investigative findings to the SSA. In addition, several residents experienced multiple elopements, with documentation that one resident followed others out back doors and another exited through doors into a hospital area, yet the facility’s investigation files lacked clear timelines, comprehensive staff interviews, identification of information sources, and root-cause analyses of exit-seeking behavior. Staff interviews confirmed that while nurses submitted occurrence reports and SSA notifications and discussed root causes informally, management did not consistently document thorough investigations or root-cause findings as required by facility policy.
The facility failed to provide adequate supervision and effective elopement-prevention interventions for several cognitively impaired, exit-seeking residents who were known elopement risks. Despite assessments, care plans, anti-wandering devices, and door alarms, residents repeatedly exited through front and back doors without timely staff redirection or alarm response, and some elopements were not properly documented in the EHR. One resident with dementia and short-term memory loss was not care planned for elopement until after multiple attempts, and another resident with severe cognitive impairment left through sliding doors unnoticed. A resident with an anti-elopement alarm on her wheelchair repeatedly triggered the door alarm throughout the day, yet staff did not effectively respond, allowing her to exit unsupervised and fall on stairs, sustaining minor injuries.
The facility failed to provide meaningful, resident-centered activities for multiple dementia residents in the memory care unit, resulting in individuals sitting idle in dining and common areas, staring at blank or inappropriate televisions, sleeping in chairs, or wandering hallways without engagement. Activity sessions were canceled or not implemented as scheduled, and when paper activities like word searches were offered, only a few residents participated while others received no assistance, including a resident who repeatedly requested glasses and another who did not speak English. Sitters did not help residents with activities, and an activity staff member spent time on a computer and left the unit for other duties. Staff interviews revealed that management directed the limitation of music and physical activities, that residents were often left in bed because it was easier for staff, that floor staff did not conduct activities in the absence of the activity staff, and that the posted activity calendar, which included exercise, trivia, book club, and weekend "Resident Choice Day," was frequently not followed despite a policy requiring meaningful activities tailored to dementia residents.
A hospice resident with metastatic cancer and behavioral symptoms received multiple sedating medications, including quetiapine, hydrocodone, morphine, lorazepam, olanzapine, and prednisone, without thorough assessment for unnecessary drugs, duplicate therapy, or adverse consequences. Despite documented behavioral issues, falls, cognitive decline, and moderate to severe pain scores, staff reported no concerns with the medication regimen. The resident became increasingly sedated, was found unconscious with minimal response to painful stimuli, and was sent to the hospital, where documentation linked the clinical picture to disease progression and medication effects, including opioid use and possible steroid-induced psychosis.
A resident with a documented history of opioid-induced constipation and prior fecal impaction was admitted from the hospital, where providers had noted difficulty balancing opioid use and constipation medications. On admission, facility documentation characterized the resident as having normal stool and rarely needing laxatives. Over the following weeks, bowel records showed multiple days without a bowel movement, yet the MAR reflected no scheduled or PRN constipation medications given. Nursing notes documented no constipation despite absent bowel sounds, while subsequent hospital imaging revealed an extensive rectal stool burden concerning for stercoral colitis. Staff interviews confirmed that the prolonged absence of bowel movements was not reported, the resident received no PRN bowel medications, and there was no specific bowel and bladder management policy.
Staff failed to follow hand hygiene practices while caring for a resident with weeping, hot lower legs who had been started on antibiotics for cellulitis. One staff member removed TED hose from the resident’s weeping left leg and then immediately assessed the right leg without changing gloves or performing hand hygiene. Another staff member, after applying TED hose to the weeping leg while gloved, continued to handle the resident’s food, pillow, and personal items and answered a cell phone by placing her gloved hand into her pocket, all without changing gloves or performing hand hygiene, contrary to the facility’s hand hygiene policy.
The facility failed to protect residents from abuse when one resident without capacity to consent was found in a common area with another resident’s hand inside her brief, and the subsequent investigation did not include interviewing or assessing other residents who might have been affected. In a separate event, a resident shook his spouse’s head and later sprayed water in her face with a spray bottle when she was tired at dinner, causing her agitation, while both continued to share a room and she spent most of her time and slept in common areas due to ongoing behaviors between them, as reflected in her care plan.
Failure to Prevent and Manage Pressure Ulcer Leading to Severe Sacral Wound
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate prevention and treatment of pressure ulcers and to complete and document required skin and wound assessments for a dependent resident. The resident was admitted from a hospital with red skin on the right elbow, a left neck surgical laminectomy site, and a left shin abrasion, and was totally dependent on staff for bed mobility, transfers, dressing, toileting, personal hygiene, and bathing, and had a Foley catheter. Within six days of admission, weekly wound documentation showed the resident had developed bilateral buttock moisture-associated skin damage (MASD) of significant size. The resident was then hospitalized for confusion and hyponatremia, and hospital wound care documented a deep tissue pressure injury to the sacrum that evolved into a Stage III pressure injury with yeast. When the resident returned to the facility, the facility’s readmit screener documented MASD to the buttocks and a yeast rash to the buttocks and groin, but no sacral pressure injury. Subsequent facility wound documentation showed that a few days after readmission, the resident had scattered ulcerations with MASD to the buttocks and a Stage III pressure ulcer to the right medial lower buttock, and that orders for treatment were requested from the physician. By the following week, the weekly wound observation tool documented that the Stage III bilateral buttock wounds had merged into one large unstageable pressure ulcer with odor and moderate purulent drainage, indicating potential infection. During this same period, there were no documented skin/wound assessments for the week leading up to the resident’s transfer back to the hospital, and a staff member later stated she did not know where the assessments were or why they were not done, and could not explain why no one reported that the wound was worsening. The care plan listed multiple skin integrity problems and interventions, including skin evaluations, routine turning and repositioning, CNA skin inspections with routine care, monitoring nutrition, and weekly nurse skin evaluations, but did not specify task frequency for some interventions. Interviews further described staff awareness and handling of the resident’s condition and behaviors. A family member reported that staff were frequently frustrated by the resident’s constant need for attention and anxiety, and that he repeatedly educated management about the resident’s high anxiety and hyperfocus, and did not understand how staff could report spending so much time with the resident yet not recognize how sick he was with infection. A staff member stated the sacral wound was facility-acquired, that the resident became obtunded related to opioids, and that she was unaware of the resident’s excessive water intake until after a hospital stay. Another staff member who completed a readmission history and physical found the resident febrile, with therapy unable to mobilize him due to pain, and described the resident as heavily sedated on an intense pain regimen that predated his stay. This staff member stated there were many opportunities for improvement in nursing assessments and that the facility could not handle the resident’s complex psychiatric and pain needs. Ultimately, the resident was transferred to the hospital with a large sacral decubitus wound with purulent tissue, surrounding cellulitis, and radiologic evidence of a severe sacral ulcer with erosion nearly to the coccyx and associated abscess and necrotizing soft tissue infection.
Improper Labeling, Dating, and Handling of Refrigerated Food Items
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage practices when, during an observation of the walk-in cooler, multiple food items were found undated or unlabeled, contrary to the facility’s Food Safety Requirements policy. Specifically, two zip-lock bags of slimy, sliced tomatoes were not dated; a gallon zip-lock bag of ground meat was not labeled with the food type or date; and separate gallon zip-lock bags of sliced ham, sliced roast beef, and sliced cheese were all undated. In addition, a cup of sliced strawberries had no date. Staff interviews revealed that kitchen staff had observed mold on strawberries upon delivery and would usually attempt to pick out the molded strawberries, and another staff member acknowledged awareness of ongoing dating issues with refrigerated foods. A further interview indicated that moldy dinner rolls had been served on one occasion, prompting staff to retrieve the rolls from residents after service. The facility’s written policy required labeling, dating, and monitoring refrigerated food, including leftovers, so it would be used by its use-by date or frozen/discarded, but these requirements were not followed, placing all residents at risk for foodborne illnesses. No specific residents or their medical histories were identified in the report; the deficiency was described as affecting all residents through improper food labeling, dating, and handling practices in the kitchen and walk-in cooler.
Failure to Submit Abuse and Elopement Investigation Findings Within Required Timeframe
Penalty
Summary
The facility failed to submit investigation findings related to alleged abuse and elopement incidents to the State Survey Agency (SSA) within the required 5 working days for multiple residents. For one incident dated 1/24/26, a resident left her room and kicked another resident’s feet; the facility’s investigative findings for this event were not submitted to the SSA until 2/4/26, which was 11 days after the incident was reported. For another incident dated 3/20/26, one resident kicked another resident in the legs while both were in wheelchairs, with no injuries reported and immediate separation of the residents; review of records showed no evidence that the facility ever submitted investigative findings for this incident to the SSA. Additionally, review of the SSA reporting site showed that the facility made initial reports of elopement for a resident on 7/18/25 and 2/1/26 but did not submit final investigation reports within the required 5 working days. There were no final reports for either elopement incident. During an interview, a staff member stated that another staff member, who was out of the facility during the survey week, was responsible for reporting and submitting investigative findings to the SSA for abuse allegations. The same staff member confirmed the expectation that findings of any abuse allegation be reported to the SSA within 5 working days and acknowledged they could not provide investigative findings for the 3/20/26 incident. The facility’s written policy, reviewed and dated 7/15/25, required that results of all investigations of alleged violations be reported within 5 working days of the incident.
Failure to Investigate Resident Abuse and Elopements or Identify Root Causes
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and manage an allegation of resident-to-resident abuse and multiple resident elopements. In one incident, a resident in a wheelchair kicked another resident multiple times in the lower legs while both were at the nurses’ station. Nursing documentation noted the kicking and that there were no injuries, and the immediate response was to separate the residents. However, review of the facility’s abuse investigations for the relevant period showed no completed investigation related to this reported allegation of resident-to-resident abuse, and there was no documentation of investigative findings or that these findings were reported to the State Survey Agency. The facility also failed to protect the involved residents from further potential abuse. Nursing notes for both residents documented that, two days after the kicking incident, one resident was observed continually attempting to follow, communicate with, agitate, and argue with the other resident, and staff had to separate them twice. Staff communicated to others to monitor their interactions, but the notes showed that the residents continued to have problematic contact, indicating that the facility did not prevent further potential abuse between them. During interview, a staff member stated that another staff person was responsible for investigating and reporting abuse allegations, but that person was unavailable and no documentation could be produced to verify that an investigation had been completed or that results were reported to the state agency, despite facility policy requiring thorough investigation, protection of residents during the investigation, and reporting of results. The deficiency also includes failures related to multiple elopements by several residents. For one resident, an elopement investigation documented that the resident exited the facility, but the investigation lacked signatures, identification of information sources, and clear involvement of the email sender included in the file. A state abuse reporting entry indicated that this resident left through back doors, possibly following a volunteer or staff taking other residents to Mass, and was brought back by a Med-Surg nurse, but there was no documented root-cause analysis or explanation of why the elopement occurred or what interventions were implemented to prevent recurrence. Another resident eloped through doors leading into the hospital; the reportable incident was submitted to the SSA, but there were no nurses’ notes on the date of the elopement describing the event, and a note the following day only stated that the resident attempted to elope twice, reflecting incomplete contemporaneous documentation. For this same resident, the facility’s investigation of the elopement included only limited staff interviews and did not include interviews with CNAs or activity staff to establish a full timeline of the resident’s movements or to identify the root cause. A subsequent elopement by this resident into the hospital was documented in a nursing note, and the investigation consisted of an undated handwritten note stating that people came into the unit looking for someone in the hospital, left to go to Med-Surg, and the resident followed them out the door, with the door alarm functioning and the resident returning to the unit. There was no documented timeline, no detailed interviews, and no analysis of the effectiveness of elopement-prevention interventions. A third resident had multiple documented elopements over several months, with investigation files that often contained only brief summaries, incomplete checklists, or limited supporting documents such as bounds reports or invoices for a wander guard system. Across these events, the facility did not consistently document root-cause analyses or assessments of the resident’s exit-seeking behavior, and the record notes that this failure to identify and document root causes led to a fall with injury for this resident. Interviews with staff confirmed that the facility’s practice did not align with its stated expectations. One staff member reported that a former staff person had previously conducted incident investigations but had left months earlier, and that the expectation for investigations was to determine the root cause of incidents and monitor residents to ensure interventions were implemented. Another staff member stated that after each elopement, the nurse would file a report to the SSA and update the care plan, after which management was supposed to conduct a full investigation. A further interview indicated that nurses entered occurrence reports and submitted SSA reports to track elopements and that staff discussed root causes but did not maintain documentation of those analyses. These statements, combined with the incomplete and inconsistent investigation records, demonstrate that the facility did not carry out or document thorough investigations, root-cause analyses, or protective measures as required by its own abuse investigation and reporting policy.
Failure to Prevent Elopements and Respond to Anti-Wandering Alarms
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and effective interventions to prevent elopements for multiple residents identified as at risk for wandering, despite existing assessments and care plans. Staff reported that residents at risk for elopement were identified by the MDS nurse on admission and quarterly, and that anti-wandering devices and door alarms were in place, particularly at the front door. However, staff also indicated that wander guard bracelets could be applied without formal assessment, and that information about elopement risk was communicated via paper “brain” sheets. The facility had a written SBAR and procedure for anti-wandering door alarms, including immediate resident location checks and following an elopement procedure, but the report shows these processes were not effectively implemented. One resident with a documented elopement risk and dementia was care planned to have an anti-wander device on her wheelchair and to be involved in activities and redirected when she attempted to exit. She eloped on at least two occasions: once when she went through the first set of doors and was found in a corridor by another resident, and another time when she exited through back doors, apparently following others going to Mass, with no alarms triggered. Her care plan documentation was inaccurate regarding the presence of a wander guard door in 2024, and there was no nursing documentation of the February elopement in her electronic health record. Another resident with severe cognitive impairment (BIMS score of 3) and an elopement risk care plan that included redirection, diversional activities, and ensuring door alarms were activated, was able to get out between the sliding front doors when someone was entering or exiting, and no one saw her leave, contrary to the care plan interventions. A further resident with dementia and short-term memory problems was identified as at risk for elopement, yet his elopement care plan and interventions were not initiated until after he had already eloped twice in one afternoon through different doors. He later eloped again, but the corresponding nursing note was not provided. Another resident, described as exit seeking and very independent with behavioral issues toward staff, had an anti-elopement alarm device on her wheelchair that sounded as she approached the door and had been near the door setting off the alarm throughout the day. Despite this, she was able to push open the main entrance sliding doors, exit, and then fall while attempting to walk down stairs, sustaining an abrasion and bruising and requiring hospital evaluation. Staff interviews indicated that interventions such as 1:1 monitoring, taking her outside, and diversional tasks were used, and that elopements were tracked via occurrence reports and state submissions, but the facility failed to identify the need for continuous one-on-one monitoring for this resident, failed to respond appropriately to the anti-elopement door alarm, and failed to prevent her unsupervised exit and subsequent fall. Activity staff also reported that, after a staffing reduction, there were no organized activities after 5 p.m., despite prior recognition that increased monitoring and activities during late afternoon hours were needed for an elopement-risk resident.
Failure to Provide Meaningful Activities for Dementia Residents in Memory Care Unit
Penalty
Summary
The deficiency involves the facility’s failure to provide meaningful, resident-centered activities to meet the needs of multiple residents with dementia in the memory care unit. Surveyors observed residents sitting in dining and common areas without any activities, including a resident with a BIMS score of 0 repeatedly scratching her arms while staring at a turned-off television, and another resident wandering the unit and running into walls. On another observation, the scheduled activities were canceled due to weather, and the activity staff member present was working on care plans on a computer while residents sat with newsletters in front of them, many staring at the floor or sleeping. Only some residents participated in the offered activities, while others, including residents with severely and moderately impaired memory, did not participate and were not engaged. During the same observation period, residents were given a word search activity, but only a few actively worked on it. Sitters, who were present to watch and redirect residents, sat at the tables and did not attempt to assist residents with the activity. One resident repeatedly stated she needed her glasses to see the paper, but no staff obtained her glasses. A resident who did not speak English sat staring down the hall without engagement, and another resident with severe cognitive impairment wandered the hall. The activity staff member stated she had other duties in another unit and left, and later that evening, surveyors observed one resident sleeping in a recliner and another staring at a wall while cartoons played on the television. Interviews with staff revealed that activities in the memory care unit were limited and often not implemented as scheduled. The activity staff member reported she was instructed by management to avoid music and physical activities because staff believed these would cause residents to become agitated, and that she was told to limit activities to calming options only. She also stated that residents were often left in bed and not taken to activities because it was easier for staff, and that floor staff did not provide activities when she was not present, preferring residents to sit quietly. Other staff confirmed that activities usually did not occur in the memory care unit, that activities observed during the survey were a show for surveyors, and that the activity calendar was not followed. The memory care activity calendar showed “Resident Choice Day” on all weekends and listed trivia, exercise/stretching, and book club on weekdays, while the facility’s activities policy required activities to enhance well-being, physical activity, cognition, and to provide meaningful activities for residents with dementia.
Failure to Assess Hospice Resident’s Polypharmacy and Sedation Risk
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s drug regimen was free from unnecessary medications and thoroughly assessed for sedation, duplicate therapy, and adverse consequences. A hospice resident with metastatic cancer, delirium, psychosis, and impulsive, intermittently aggressive behavior was receiving multiple medications including antipsychotics, opioids, benzodiazepines, and a steroid. Hospice staff discontinued some medications and added morphine and lorazepam, while the resident also continued on quetiapine, hydrocodone, prednisone, and later received a one-time dose of olanzapine. Facility staff A and B reported that they had no concerns with the resident’s medications despite the combination of psychotropic and sedating drugs. The resident had been ambulatory on arrival to the facility but became weaker with multiple falls, nonsensical and incoherent speech, and combative and unsafe behavior. One-to-one supervision was initiated due to impulsivity and aggression, and staff questioned whether pain contributed to the aggressive behavior. The resident’s pain scores documented on the Medication Administration Record over three days showed moderate to severe pain levels (5/10, 3/10, and 7/10), while the resident continued to receive multiple sedating medications, including quetiapine every eight hours, hydrocodone three times daily, lorazepam as needed every four hours, morphine as needed every four hours, and prednisone daily. On the day before transfer to the hospital, the resident received olanzapine, prednisone, hydrocodone, two doses of lorazepam, and morphine; on the day of transfer, the resident received lorazepam, morphine, and prednisone. When a family member arrived at the facility, they found the resident unconscious with minimal response to painful stimuli and appearing sedated, and they requested transfer to the hospital. The family reported the resident had been more sedated at the facility lately, and the emergency room provider reportedly told the family the resident had an overdose of medications. Hospital documentation noted altered mental status, hypoxia, and that the resident’s dementia and chronic encephalopathy may have been exacerbated by disease progression and opioid use, possible steroid-induced psychosis, and electrolyte imbalance. The facility did not identify or address the resident’s medication regimen as a contributing factor to sedation or assess for duplicate therapy and adverse consequences prior to the resident’s transfer.
Failure to Monitor and Treat Constipation in Resident With Opioid-Induced Constipation History
Penalty
Summary
The facility failed to monitor and manage constipation for a resident with a known history of opioid-induced constipation and prior use of constipation medications. Hospital records showed the resident had been admitted with a 9.6 cm fecal impaction and that the hospital physician documented the resident could go up to five days without a bowel movement, likely due to opioid use, and was working on balancing opioid-induced constipation with constipation medications. Upon admission to the facility, the Admit/Readmit Screener documented that the resident had normal formed stool and rarely or never depended on laxatives, despite this history. Facility bowel documentation later showed gaps in bowel movements, including no bowel movement for several days. Review of the Medication Administration Record for March and April showed the resident did not receive any scheduled or PRN constipation medications during the stay. Bowel documentation indicated no bowel movement from 3/29 to 4/3, followed by diarrhea on 4/4 and a putty-like stool on 4/5. A nursing progress note on 4/6 documented a flat, non-tender abdomen with no bowel sounds and no constipation, while hospital records from the same date, after readmission, showed an extensive stool burden distending the rectum to 8.8 cm with findings concerning for stercoral colitis. Staff interviews revealed that no one reported the resident had gone six days without a bowel movement, the resident had gone without any PRN bowel medications, and the facility did not have a policy specific to bowel and bladder management.
Failure to Perform Hand Hygiene During Wound and Skin Care
Penalty
Summary
Facility staff failed to ensure proper hand hygiene during care of a resident with suspected infected lower extremities. During an observation, two staff members entered the room of a resident who had reported weeping and hot lower legs. One staff member removed the TED hose from the resident’s left leg, noted that the leg was hot to the touch and weeping edema fluid, then moved directly to the right leg, removed the TED hose, and assessed that leg without changing gloves or performing hand hygiene between contact with the weeping left leg and the intact right leg. This same staff member later stated she believed she had completed all hand hygiene opportunities but realized, when questioned, that she had moved from one leg to the other without performing hand hygiene. The resident had been started on Cipro for cellulitis on the morning of the observation. A second staff member returned to the room with new TED hose and socks, donned gloves, and assisted with applying the TED hose. This staff member applied TED hose to the resident’s left leg, observed weeping fluid from the skin, and then proceeded to clean up the room while still wearing the same contaminated gloves. While gloved, she touched the resident’s food on the bedside table, handled the resident’s pillow and placed it on the chair where the resident was sitting, and put her gloved hand into her clothing pocket to turn off her ringing cell phone. She did not perform hand hygiene or change gloves after contact with bodily fluids and before touching other items in the room. After leaving the room, she stated she had not thought about performing hand hygiene after finishing application of the TED hose. The facility’s hand hygiene policy required hand hygiene after handling contaminated objects, when moving from a contaminated site to a clean body site during resident care, and after handling items potentially contaminated with blood or bodily fluids.
Failure to Protect Residents From Sexual and Physical Abuse by Other Residents
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from abuse, including sexual and physical abuse, by other residents. In one incident, a resident without capacity to consent was found in a common area with another resident’s hand inside her brief up to the wrist. Staff immediately separated the residents, and the incident was reported to the State Survey Agency; however, the facility’s investigation did not include interviewing or assessing other residents who might have been present or potentially affected by similar sexual abuse incidents. A staff member also reported that the incident was initially reported under the wrong license type because they were unaware the facility held both an adult day care and a skilled nursing facility license. In a separate incident, a resident became upset with his spouse, also a resident, during dinner and shook her head to wake her, then later sprayed water in her face with a spray bottle after staff had intervened and moved her to the nurses’ station. The spouse became agitated by these actions. Observations showed that the couple continued to share a room, with both residents’ nameplates and belongings present. Staff interviews indicated that the spouse who was the target of the behavior was usually kept out of the room and spent most of her time and slept in common areas or by the nurses’ station due to ongoing behaviors between the two. The care plan for the spouse reflected that she was not to be in the room when her husband was present unless both wanted to be there, and staff were to intervene if yelling occurred, based on the prior incident of head shaking and use of the spray bottle.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
