Yellowstone River Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Billings, Montana.
- Location
- 2115 Central Ave, Billings, Montana 59102
- CMS Provider Number
- 275029
- Inspections on file
- 27
- Latest survey
- December 31, 2025
- Citations (last 12 mo.)
- 31
Citation history
Health deficiencies cited at Yellowstone River Nursing And Rehabilitation during CMS and state inspections, most recent first.
A resident dependent on staff for toileting and hygiene activated her call light for over four hours without receiving needed assistance to change her brief. Multiple staff entered the room but did not provide care or turn off the call light, and communication breakdown at shift change contributed to the delay. The resident's family, unable to reach the facility, contacted local police for a welfare check.
A facility licensed for 160 beds did not employ a full-time social worker who met regulatory requirements, as the staff member in the social services director role held a psychology degree instead of a social work degree and lacked the required supervised healthcare experience. Despite the facility's census being below 120, regulations require a qualified social worker based on licensed bed count, not census. This deficiency was linked to concerns about meeting residents' mood, behavioral, and psychosocial needs.
Two residents did not have comprehensive, person-centered care plans with measurable objectives and timeframes. One resident with an indwelling catheter lacked specific care plan details for enhanced barrier precautions despite infection risk, while another resident with emotional and behavioral needs did not have individualized psychosocial interventions documented. Staff interviews and record reviews confirmed that care plans were not consistently updated to reflect residents' changing clinical and psychosocial needs.
A resident admitted for rehab services did not receive a complete provider assessment after refusing to continue with the initial provider due to concerns about bedside manner. The provider's visit was cut short, and no subsequent provider completed the required assessment or history and physical, leaving the resident's care needs unaddressed during her stay.
A resident with a history of alcohol abuse and ongoing emotional distress repeatedly requested mental health counseling and expressed concerns about staff treatment. Despite documented behavioral health needs and facility policy requiring assessment and referral, no counseling or mental health services were arranged, and no referrals were documented during the resident's stay.
A resident with a history of mental health concerns, including depression, anxiety, paranoia, and care refusals, did not receive individualized social services or behavioral interventions. The facility's assessments and care plan lacked accurate documentation and specific strategies for staff to address the resident's symptoms, and no evidence was found of referrals for needed mental health services.
A resident did not receive appropriate care for existing pressure ulcers, and the facility failed to implement effective measures to prevent new ulcers from developing. Surveyors found that necessary interventions and monitoring were not consistently provided.
A resident with severe protein calorie malnutrition and recent stroke experienced significant weight loss over one month. The resident was observed not receiving required assistance with eating, resulting in missed meals and visible difficulty during mealtimes. Documentation of required weekly weights was incomplete, and recommended dietary interventions were not implemented or monitored in a timely manner.
A grievance box was placed on a counter and blocked by a trash can, making it inaccessible to residents using wheelchairs. Staff sometimes had to assist residents in submitting grievances, and a resident reported being unable to submit grievances anonymously due to the box's placement and design.
Multiple residents reported and were observed receiving meal trays late and at improper temperatures, with some expressing significant hunger while waiting. Staff interviews confirmed ongoing issues with timely meal delivery to resident rooms, attributed to kitchen delays, unclear meal schedules, and inconsistent staff performance.
Staff cleaned a resident's room and disposed of personal items without the resident's presence or clear consent, despite the resident's history of homelessness and hoarding. The care plan did not specify how to involve the resident in decisions about his belongings, and there was no documentation of his agreement to the process. The resident was frustrated by the loss of his items, and the facility lacked a policy addressing room cleaning or hoarding.
Two residents with edema did not receive prescribed compression wraps or leg elevation as ordered by their physicians. Despite visible swelling and clear care plan directives, staff failed to apply the required interventions and inaccurately documented that treatments were provided. Staff interviews confirmed inconsistent application of the prescribed care.
Two residents did not receive respiratory care as ordered, including one who was observed multiple times without prescribed oxygen or with an empty tank and no oxygen warning sign posted, and another whose CPAP machine was unused, obsolete, and not maintained, despite staff documentation indicating regular use.
A resident with a traumatic brain injury and a history of elopement risk left the facility unsupervised through unsecured doors that lacked a wander guard alarm system. The resident was found by law enforcement after being unattended for about 45 minutes. Staff interviews and record reviews revealed that required checks of wander guard devices and door alarms were not consistently performed, and some staff were unclear about their responsibilities regarding elopement prevention.
Staff lacked the necessary education and clear procedures to monitor and verify the functionality of the wander guard alarm system for residents at risk of wandering or elopement. Multiple staff members were unsure of their responsibilities, and required checks of devices and exit doors were not consistently performed or documented, despite care plans and facility policy mandating these actions.
A resident exited the facility through a set of doors not equipped with a wander guard alarm system, allowing them to leave the property and access a public road without staff supervision. The facility's investigation did not address the lack of alarms on the initial exit doors, focusing only on the alarmed emergency egress doors, and failed to identify this as the root cause of the elopement.
A resident experienced an unwitnessed fall after sliding out of a chair in the dining room. Although the IDT identified a new intervention to have the resident sit on a couch instead of a chair, this intervention was not added to the care plan, leaving direct care staff without access to the updated fall prevention strategy.
The facility did not ensure that meals were served at appetizing and safe temperatures, as evidenced by multiple residents and staff reporting that food delivered to rooms was often cold and that yogurt was sometimes served warm. Resident council minutes over several months also documented ongoing concerns about cold food.
A resident was temporarily placed on a mattress on the floor in a storage area of the secure memory care unit due to a lack of available rooms. The area lacked a bathroom, sink, and call light, and staff monitored the resident and assisted with toileting in another part of the unit. The placement followed an unsuccessful attempt to move the resident to a regular unit, where wandering behaviors made it unsafe.
Two residents experienced room changes without receiving advance written notice or an explanation for the moves, as required by facility policy. Documentation was missing in both the EHR and progress notes, and representatives were not informed of the changes, only discovering them after the fact.
A resident's representative was not notified when the resident experienced increased confusion and agitation, resulting in a transfer to an acute care hospital for psychiatric evaluation. Although the representative was informed about an earlier incident of agitation, there was no documentation or communication regarding the hospital transfer, and the representative only became aware of the situation through another family member.
A resident was temporarily housed in a storage area within the secure memory care unit that lacked a sink and toilet, due to all regular rooms being occupied. Staff monitored the resident and assisted with toileting by escorting the individual to a shower room elsewhere in the unit. The area was confirmed to have no bathroom facilities during this time.
A resident was placed to sleep on a mattress on the floor in a storage room within the secure memory care unit that lacked a functioning call light system. Staff confirmed the resident spent at least one night in this room due to all regular rooms being occupied, and direct observation verified the absence of a call light.
A facility failed to limit PRN anti-anxiety medication to 14 days for a resident and did not provide adequate indication for antipsychotic use for another. One resident received Diazepam PRN for over eight months without documented anxiety, and the physician did not justify the lack of dose reduction. Another resident involved in altercations was prescribed Sertraline and later Seroquel without documented behaviors, and side effects were not consistently monitored. Staff interviews revealed documentation inconsistencies and a lack of questioning physician orders.
The facility failed to employ a Certified Dietary Manager, leading to increased risks for residents receiving nutritional services. Observations revealed issues with hygiene supplies, kitchen cleanliness, and pest control. The dietary manager, in the position for three months, is still completing certification and has not collaborated directly with the contract dietician, who visits bi-weekly and primarily works with the IDT.
The facility failed to maintain sanitary conditions in the kitchen, with issues such as lack of handwashing supplies, grease buildup, and mouse droppings. Food items were not labeled or dated, and staff did not wear beard coverings. Cleaning logs showed infrequent cleaning, and facility policies on food storage were not followed.
The facility failed to address kitchen cleanliness and pest control issues effectively. Observations revealed grease buildup, nonfunctional equipment, and mouse droppings in storage areas. Staff interviews indicated a lack of awareness about pest control frequency, and the QAPI program did not identify current concerns despite previous identification of issues.
The facility failed to maintain an effective pest control program, with observations of ants, beetles, and mouse droppings in various areas, including a resident's room and the kitchen. Staff interviews confirmed awareness of the pest issues, but pest control services had not been completed since March 2024, despite the facility's policy for ongoing pest control.
The facility failed to invite residents to participate in their care plan meetings, affecting four residents. One resident reported never attending a meeting despite staff mentioning them, while another had not been invited since the previous year. A third resident had not attended a meeting in several months, and a fourth was unaware of care plans altogether. Staff acknowledged being behind on scheduling these meetings.
The facility failed to maintain a clean and sanitary environment, as evidenced by reports of bugs and dirty conditions in several residents' rooms and common areas. Despite residents' complaints and staff observations, there was a lack of effective action to address the issues. Housekeeping staff were assigned daily cleaning tasks, but persistent problems indicated non-compliance with the facility's cleaning policy.
The facility failed to properly dispose of discontinued medications for two discharged residents. Insulin pens labeled for these residents were found in the medication cart, along with several other pens with illegible or missing labels. A staff member was unaware of the correct procedure for handling these medications, contrary to the facility's policy requiring their destruction or return to the pharmacy.
The facility's medication error rate was 11.54%, exceeding the acceptable threshold. An LPN administered incorrect dosages and types of medications to two residents, including vitamin D3 and a multivitamin with minerals, and a cranberry tablet without a specified dosage. The errors were acknowledged by the LPN during a follow-up interview.
A resident experienced wrist pain due to inadequate wheelchair armrest support, leading to frequent repositioning attempts. The facility identified the issue but delayed follow-up with the wheelchair provider, resulting in a deficiency in maintaining the resident's highest practicable level of functioning.
Two residents reported rough handling and degrading language by a staff member, leading to an investigation that substantiated the abuse allegations. The staff member was suspended and did not return to work.
A facility failed to recognize a concave mattress as a potential restraint for a resident and did not conduct a risk assessment, obtain consent, or monitor its use. Staff interviews indicated the mattress was used to prevent falls due to the resident's history of falls and injuries. However, the resident's medical record lacked documentation of these necessary procedures.
A diabetic resident reported long, curling toenails, indicating a lack of effective foot care. Staff interviews revealed confusion about scheduling podiatry appointments, with one staff member uncomfortable cutting the resident's nails due to health conditions. The resident's care plan lacked documentation of podiatry needs, and no appointments were recorded in the electronic health record.
A facility failed to address a trip hazard by using a large mattress as a fall mat, obstructing a resident's access to the restroom and causing a staff member to trip. Additionally, a resident was exposed to hazardous materials by being allowed to keep bug spray in their room, despite potential health risks outlined in the Safety Data Sheet.
The facility failed to employ a competent Dietary Manager, leading to numerous deficiencies in the kitchen, including unsanitary conditions and nonfunctional equipment. Observations revealed issues such as grease buildup, mouse droppings, and unlabeled food items. The dietitian did not regularly consult with the dietary manager, who was still completing certification. A grievance about bugs in the food was filed, and staff acknowledged ongoing issues with mice.
A facility failed to follow enhanced barrier precautions during wound care and medication administration for a resident, as a staff member did not wear a gown during these procedures. Additionally, a worn recliner in a resident's room was not repaired, creating an uncleanable surface. Despite ongoing training on infection control, there was a misunderstanding among staff about when gowns should be worn, and no maintenance requests were made for the damaged recliner.
The facility failed to maintain essential kitchen equipment, including the oven, refrigerators, and ice machine, which were non-functional for an extended period. Observations revealed no paper towels near sinks, a warm dessert refrigerator, and a plugged sink drain. Staff reported issues through the TELS system, but maintenance logs lacked documentation of repairs.
Failure to Respond Timely to Resident Call Light for Dependent Personal Care
Penalty
Summary
Staff failed to respond in a timely manner to a resident who required assistance with activities of daily living, specifically with changing briefs due to urinary and bowel incontinence. The resident activated her call light, which remained on for over four hours, and multiple staff members entered her room but did not provide the needed personal care or turn off the call light. The resident ultimately contacted a family member for help, who, after being unable to reach the facility, called the local police to conduct a welfare check. Interviews with staff revealed that shift change communication was lacking, as incoming staff were not informed of the resident's need for assistance. Staff prioritized other residents based on perceived urgency and did not follow through with the resident's request, despite being aware of her call light. Documentation showed that staff were instructed to leave call lights on until all resident needs were met, but this led to confusion and further delay in care. The resident was dependent on staff for toileting and hygiene, as indicated by her care plan and assessment, and had a history of urinary and bowel incontinence. Despite being checked on earlier in the day, her needs were not met during the evening shift, resulting in an extended period without necessary personal care. Facility records confirmed the prolonged call light response time and the lack of timely assistance provided to the resident.
Failure to Employ Qualified Full-Time Social Worker in Facility Licensed for Over 120 Beds
Penalty
Summary
The facility failed to hire and employ a full-time social worker who met the regulatory requirements for a facility licensed for more than 120 beds. Specifically, the facility was licensed for 160 beds, but the individual in the social services director position held a bachelor's degree in psychology rather than in social work, and did not have the required one year of supervised experience in a healthcare setting. Another staff member working in a social services role also did not have a degree. The facility's job description for the social worker position required a bachelor's degree in social work and a state social work license, but the current staff member did not meet these qualifications. Interviews with facility staff revealed that the facility's census had never reached 120 residents, and staff believed that having two staff members in social services roles was sufficient to meet regulatory requirements. However, regulatory review confirmed that the requirement for a qualified full-time social worker applies to facilities with more than 120 beds, regardless of current census. The report also referenced related concerns with residents not receiving necessary care and services for mood, behavior, and psychosocial needs, as outlined in F656 and F740.
Failure to Develop Person-Centered Care Plans with Measurable Objectives
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes for two of eight sampled residents. For one resident with an indwelling urinary catheter and a history of spinal cord dysfunction and obstructive uropathy, the care plan did not include specific information regarding enhanced barrier precautions, despite the resident's frequent catheter changes and risk for urinary tract infections (UTIs). The care plan only referenced general infection control precautions and did not address the need for enhanced measures, even though the resident had experienced a UTI and was placed on antibiotics. For another resident with a history of alcohol abuse (in remission) and significant emotional and behavioral needs, the care plan lacked a comprehensive, person-centered focus on emotional and behavioral interventions. Although the resident exhibited emotional instability, anxiety, and concerns about staff interactions, the care plan primarily included monitoring and medication interventions without detailing specific strategies to address the resident's psychosocial needs during episodes of distress. The psychosocial assessment and social service notes documented the resident's emotional challenges and requests for mental health support, but these were not reflected in the care plan interventions. Interviews with facility staff revealed that while the interdisciplinary team was involved in care planning, there were gaps in updating care plans to reflect changes in residents' clinical or psychosocial status. Staff acknowledged that information about enhanced barrier precautions and psychosocial interventions should have been included in the care plans but were not consistently added following assessments or team discussions. The facility's policy required comprehensive, person-centered care plans with measurable objectives and timeframes, but this was not followed for the two residents in question.
Failure to Complete Required Provider Assessment After Resident Refusal
Penalty
Summary
A provider failed to complete a comprehensive assessment and review of a resident's total program of care during a required visit. The resident, who was admitted for rehabilitation services following a hospital stay for multiple medical conditions, expressed dissatisfaction with the initial provider's bedside manner and felt her concerns were not adequately addressed. During the provider's first visit, the resident became upset and asked the provider to leave before a physical exam or full assessment could be completed. The provider documented that the assessment was incomplete and noted the resident's refusal to continue the visit. Following this incident, the resident did not receive a subsequent visit from another provider to complete the required assessment, history and physical, or to make recommendations for ongoing care. Staff attempted to arrange for the resident to be seen by other providers, but the resident either refused or the attempts were unsuccessful. As a result, the resident's comprehensive care needs were not fully evaluated or addressed during her stay, contrary to facility policy and regulatory requirements.
Failure to Provide Behavioral Health Services Following Resident Request
Penalty
Summary
A deficiency occurred when the facility failed to provide necessary behavioral health care and services to a resident who requested mental health counseling. The resident, admitted with a history of alcohol abuse (in remission), exhibited consistent emotional behaviors and expressed concerns about her care and treatment by staff from the time of admission. She reported feeling mistreated, submitted a grievance regarding staff interactions, and specifically requested a different provider after expressing dissatisfaction with her assigned provider. Despite these documented concerns and requests, the resident did not receive access to mental health counseling or services during her stay. Interviews with facility staff revealed that the resident's emotional and behavioral issues were recognized by staff, including daily fluctuations in mood and difficulty settling into the facility. Staff acknowledged the resident's request for mental health services and noted her history of mental health concerns. However, there was no documentation of any referrals made for counseling, therapy, or mental health services, even though the facility's policy required monitoring, documentation, and appropriate follow-up for behavioral health needs. The social services staff member responsible for coordinating such services confirmed that no referrals were made, and the facility was unable to provide documentation of any behavioral health service referrals for the resident. The resident's medical record and care assessments consistently documented her emotional distress, paranoia about medications, and ongoing conflicts with staff. Multiple progress notes described her as excitable, emotional, and having difficulty regulating her emotions. The facility's own behavioral health policy outlined the need for timely assessment and referral for behavioral health services, but these steps were not completed for the resident, despite clear indications and requests for such support.
Failure to Provide Individualized Social Services and Behavioral Interventions
Penalty
Summary
The facility failed to provide individualized, medically-related social services and did not accurately or thoroughly assess a resident's mood, behavior, and psychosocial status. The resident in question exhibited mood symptoms, took an antidepressant, displayed anxiety, paranoia, frequently refused care, and acted out toward others. Despite these ongoing concerns, the facility did not ensure her care plan included specific, individualized interventions for staff to use when the resident displayed symptoms or concerns related to mood, behavior, or psychosocial issues. There was also no documentation of referrals for mental health services, even though such a need was identified by staff. Record reviews and staff interviews revealed inconsistencies and omissions in the resident's assessments and care planning. The psychosocial assessment contained errors, such as an impossible BIMS score, and failed to document interventions for care refusals or behavioral symptoms. Progress notes lacked consistent and individualized interventions, with some entries appearing to be repeated from previous notes. The care plan addressed issues like depression and paranoia but only included generic interventions such as monitoring medications or providing a lock box, without specific strategies for staff to address the resident's behaviors. No documentation was provided to show that mental health referrals were made prior to the end of the survey.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through surveyor observations and documentation review, which indicated that residents either did not receive necessary interventions for existing pressure ulcers or were not monitored and assessed adequately to prevent new pressure ulcers from forming.
Failure to Provide Adequate Assistance and Monitoring for Resident with Severe Weight Loss
Penalty
Summary
A resident with a recent history of stroke and a new diagnosis of Severe Protein Calorie Malnutrition experienced a significant weight loss of 7.65% in one month. Observations revealed that the resident was left asleep with an untouched breakfast tray, which was later discarded without any attempt to assist or encourage intake. During lunch, the resident was seen struggling to eat independently, with food falling off the fork and visible frustration, yet no staff assistance was provided. The care plan indicated the resident required extensive assistance with eating, but this intervention was not implemented during observed meals. Record review showed the resident was to be weighed weekly, but a required weight was missing from documentation. Despite the physician's note identifying significant weight loss and recommending a Registered Dietitian consult and nutritional supplements, there was no evidence of dietary follow-up or intervention in the progress notes. Staff interviews confirmed the resident had not been included in weight loss monitoring until after the deficiency was identified, and dietary interventions were not updated in a timely manner.
Grievance Box Inaccessible to Wheelchair Users
Penalty
Summary
The facility failed to provide a wheelchair-accessible grievance box, preventing residents who use wheelchairs from independently or anonymously submitting grievances. During observation, the grievance box was found placed on top of a counter in the main lobby, with a trash can on the floor in front of it, creating a physical barrier. The box required the lid to be pulled down to deposit a form, further complicating access for those with limited mobility. Staff confirmed that they sometimes had to assist residents in wheelchairs to submit grievances, and a resident who relies solely on a wheelchair reported being unable to reach the box and therefore had to hand grievances directly to staff, compromising anonymity. The resident also expressed a desire for the box to be more accessible and discreet.
Delayed and Improper Meal Service to Resident Rooms
Penalty
Summary
The facility failed to serve resident meal trays to rooms in a timely manner and according to posted mealtimes, resulting in multiple residents experiencing late and lukewarm meals. Observations and interviews revealed that residents who consistently ate in their rooms reported their food was often served thirty minutes late and was usually lukewarm. On several occasions, residents expressed significant hunger while waiting for their meals, with one resident rating their hunger as ten out of ten. Meals were observed being delivered after the designated end time for meal deliveries, and residents commented on the food being served late and not at the proper temperature. One resident expressed concern about the late meal affecting their ability to attend a scheduled appointment. Staff interviews confirmed that meal trays were often late getting to resident rooms, with some staff acknowledging that the facility could improve the timeliness of tray delivery. Staff attributed delays to food not coming out of the kitchen quickly enough and to the order in which halls were served. There were also reports of CNAs delaying food service due to inattentiveness. Meal delivery times were not clearly posted or communicated to residents, leading to confusion and unmet expectations regarding when meals would be served.
Failure to Respect Resident's Personal Belongings During Room Cleaning
Penalty
Summary
Facility staff failed to respect a resident's personal belongings during a room cleaning, disposing of items without the resident's presence or awareness. The resident, who had a documented history of homelessness and hoarding, kept various personal items in his room, including painted rocks, a handmade plant, and papers, none of which posed a safety hazard at the time of observation. Staff cleaned the room while the resident was absent, removed items from display, and discarded stored food, citing routine housekeeping and the need to prevent hoarding. The resident expressed frustration and distress upon discovering his items were missing or displaced, indicating he was not informed or consulted about the cleaning or the disposal of his belongings. Review of the resident's care plan showed interventions related to his history of hoarding and the need to maintain a safe environment, but did not specify how staff should ensure the resident was comfortable with the cleaning process or aware of what was being discarded. Staff interviews revealed that while the resident had previously consented to staff cleaning his room, there was no documentation or clear communication regarding which items could be removed or discarded. Additionally, the facility lacked a specific policy on hoarding or room cleaning for safety concerns, and there was no evidence of a documented agreement or contract outlining the resident's preferences or consent for the disposal of his personal items.
Failure to Follow Physician Orders for Edema Management
Penalty
Summary
The facility failed to follow physician orders for edema treatment for two residents with mobility issues. Observations revealed that both residents consistently exhibited swelling in their lower legs and feet, yet were not wearing the prescribed elastic bandages or compression stockings. Additionally, interventions such as leg elevation were not implemented as directed in their care plans. Despite these omissions, staff documented in the Treatment Administration Records that the interventions had been performed on the relevant dates. Interviews with staff confirmed that the prescribed treatments were not consistently applied, and some staff indicated that only certain nurses would perform these tasks. Review of the residents' care plans and treatment records showed clear orders for the use of compression wraps and leg elevation to manage edema. However, these interventions were not observed during multiple surveyor visits, and staff documentation did not accurately reflect the care provided. Weekly skin check assessments also failed to note the presence of edema, despite visible swelling. The lack of adherence to physician orders and inaccurate documentation contributed to the identified deficiency.
Failure to Follow Physician Orders for Oxygen and CPAP Administration
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents by not following physician orders for oxygen and CPAP administration. One resident, who had an order for continuous oxygen at 2 L per minute via nasal cannula, was repeatedly observed without oxygen or with an empty oxygen tank attached to her wheelchair. The resident's room lacked the required oxygen warning sign, and multiple empty oxygen tanks were present. Documentation indicated that oxygen was administered only 92% of the time, despite the order for continuous use. Another resident, who had an order for nightly CPAP use for obstructive sleep apnea, had not used the CPAP machine for an extended period. The CPAP equipment was found buried, dusty, missing a power cable, and without a current biomedical inspection date. Despite this, staff documentation reflected that the CPAP was applied most nights, which was inconsistent with the resident's statements and the observed condition of the equipment. The order for CPAP was eventually removed, but the order to clean the facemask remained.
Resident Elopement Due to Unsecured Exit and Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident with a traumatic brain injury and a known history of agitation and elopement risk was able to leave the facility unsupervised through unsecured doors. The resident was last seen in his room and, after a door alarm was heard, staff discovered that the resident was missing. The facility's elopement protocol was activated, and the resident was found by law enforcement approximately 0.2 miles from the facility after being unattended for about 45 minutes. The doors used for the elopement were not equipped with a wander guard alarm system, and the area was not occupied by staff or residents at the time. Interviews and record reviews revealed that the exit doors on certain units, including the one used during the elopement, had not been secured with a wander guard alarm system for at least four years. Staff believed that the emergency exit door alarms were sufficient, but these alarms only sounded when the door was opened and did not provide the same level of alert as the wander guard system. Additionally, the resident's care plan had previously included 1:1 monitoring and a wander guard device, but the monitoring was discontinued following an IDT review, and there was uncertainty among staff about the evaluation process and documentation for this decision. Further review showed that multiple other residents were assessed as being at risk for elopement and were supposed to have wander guard devices in place, with staff required to check these devices every shift. However, interviews indicated that these checks were not consistently performed, and some staff were unclear about who was responsible for ensuring the devices and door systems were functioning. The facility's own elopement policy required regular checks of both door keypads and monitoring devices, as well as immediate staff response to alarms, but these procedures were not reliably followed.
Failure to Ensure Staff Competency and Monitoring of Wander Guard Alarm System
Penalty
Summary
The facility failed to ensure that nurses and nurse aides possessed the necessary education and competencies to monitor and verify the functionality of the wander guard alarm system for residents at risk of wandering and elopement. Multiple staff interviews revealed a lack of clarity regarding who was responsible for checking the wander guard devices and exit door alarms, as well as how often these checks should occur. Staff members were unaware that not all exit doors were equipped with the alarm system, and there was no consistent process in place for verifying device or door functionality. Documentation confirming daily or shift-based checks, as required by facility policy and resident care plans, was not available during the survey. Care plan reviews for six residents identified as being at risk for wandering or elopement indicated that their wander guard devices were to be checked every shift to ensure proper function. However, the facility was not using the manufacturer's device to verify the functionality of the wander guard system for either residents or doors. The facility's elopement policy required daily checks of door keypads and nightly checks of monitoring devices, but these procedures were not being followed or documented. This lack of adherence to policy and insufficient staff education led to a deficiency in ensuring the safety and well-being of residents with elopement risks.
Failure to Identify and Address Unalarmed Exit Doors Leading to Resident Elopement
Penalty
Summary
The facility failed to conduct a thorough investigation after a resident exited the building through doors that were not equipped with a wander guard alarm system. The resident was able to leave the property, access a public road, and travel 0.2 miles on foot without staff supervision. The facility's report indicated that while the emergency egress door at the end of the hall was alarmed and staff responded to the alarm, they did not see any residents outside and subsequently contacted local law enforcement. The resident was later found and returned to the facility by police. The investigation did not address the fact that the first set of exit doors, which the resident used to leave, were not equipped with a wander guard alarm system, allowing the resident to reach the emergency egress doors and exit the facility. Interviews revealed that the interdisciplinary team (IDT) reviewed the incident, but the lack of a progress note summary in the resident's medical record was noted. Staff confirmed that certain doors in the facility, including those on the sapphire and crossroads units, were not alarmed with a wander guard system and that this was not identified as the root cause of the elopement. The rationale provided was that the second set of doors, which were emergency egress doors, were alarmed and would alert staff if a resident exited. However, the absence of alarms on the first set of doors was not addressed as a contributing factor to the resident's ability to elope.
Failure to Update Care Plan with New Fall Intervention
Penalty
Summary
A deficiency occurred when the facility failed to update a resident's care plan with a new fall intervention identified by the Interdisciplinary Team (IDT) after the resident experienced an unwitnessed fall. The resident, who was sitting in a chair in the dining room, attempted to scoot forward and slid out of the chair, landing on her buttocks. The IDT reviewed the incident and suggested a new intervention: redirecting the resident to sit on a couch instead of a chair, as she was able to get up from the couch without difficulty. This intervention was documented in the IDT event review note but was not added to the resident's care plan. As a result, the direct care staff did not have access to the updated intervention, which was necessary to address the specific circumstances of the resident's fall. The facility's policy requires that care plans be revised as information about residents and their conditions change, and that the IDT must review and update care plans when there is a significant change in condition or when desired outcomes are not met. Despite these requirements, the new intervention was not incorporated into the care plan, leading to a deficiency in care planning and communication.
Failure to Serve Meals at Appropriate Temperatures
Penalty
Summary
The facility failed to ensure that meals were served at an appetizing and safe temperature, resulting in dissatisfaction among residents. Multiple residents reported receiving meals that were not hot, with specific complaints about both breakfast and lunch trays being cold when delivered to their rooms. One resident also noted that yogurt, which should be served cold, was often delivered warm. Staff confirmed that they regularly received complaints from residents about room trays being cold. Additionally, a review of resident council meeting minutes over several months consistently documented concerns about food being served cold, both in resident rooms and in the dining room. These findings indicate that the facility did not maintain appropriate food temperatures during meal service, as evidenced by direct resident interviews, staff statements, and ongoing documentation in resident council minutes.
Resident Placed in Non-Residential Area Without Basic Amenities
Penalty
Summary
A resident was placed in a non-residential area of the secure memory care unit, specifically the Country Store, due to a lack of available rooms. The resident was found lying on a mattress on the floor in a room that lacked basic amenities such as a sink, bathroom, or call light. The area was described as a storage room with the lights off and the door partially closed. Staff interviews confirmed that the resident had been temporarily placed in this area after an unsuccessful attempt to move him to a regular unit, where he was unable to stay due to wandering behaviors. Staff also reported that, prior to being placed in the Country Store, the resident had slept on a couch in the television room, which was too bright and noisy for rest. The decision to place the resident in the Country Store was made because all rooms in the secure memory care unit were occupied, and the resident could not safely remain outside the secure unit. Staff acknowledged the absence of a call light and bathroom in the Country Store and stated that they monitored the resident closely and assisted him to the toilet in another part of the unit as needed. The area used for the resident's temporary accommodation was observed to be two open spaces with no private closet, bathroom, or sink, and was adjacent to the hallway with access to a courtyard.
Failure to Provide Written Notice for Room Changes
Penalty
Summary
The facility failed to provide written notice, including the reason for room changes, to residents and their representatives prior to making room changes for two of three residents reviewed. For one resident, records showed multiple room changes over several weeks, but there was no documentation of Notification of Room/Roommate Change forms for two of the moves, nor were any of the room or unit changes documented in the resident's progress notes. The resident's representative confirmed that they were not notified, either verbally or in writing, about the subsequent moves and were unaware of the resident's current location. For another resident, documentation revealed a room change without a corresponding Notification of Room/Roommate Change form or any mention of the move or its reason in the progress notes. The resident's representative stated they were not informed of the room change and only discovered it upon visiting and being unable to locate the resident. The facility's policy requires advance written notice, including the reason for the change, to all parties involved prior to any room or roommate assignment changes.
Failure to Notify Representative of Resident Transfer After Change in Condition
Penalty
Summary
The facility failed to notify a resident's representative when there was a significant change in the resident's condition that required transfer to an acute care hospital for psychiatric evaluation. According to interview and record review, the resident's representative was informed about an attempted elopement and agitation but was not notified when the decision was made to transfer the resident to the hospital. The representative only learned of the transfer after another family member visited the facility and was told the resident was in the hospital. Review of the resident's hospital records indicated increased confusion, agitation, and medical interventions, but facility progress notes did not document any notification to the representative regarding the change in condition or the transfer.
Resident Placed in Room Without Bathroom Facilities
Penalty
Summary
A deficiency was identified when a resident was temporarily placed in a room known as the Country Store, located in the secure memory care unit, which did not have a sink or toilet. Staff interviews confirmed that all regular rooms in the secure unit were occupied, and the resident was placed in the Country Store as a temporary measure. The area was described as two open spaces used for storage, lacking both a sink and a bathroom. Staff reported that they monitored the resident closely and assisted with toileting by escorting the resident to a shower room at the other end of the unit. Observations confirmed the absence of bathroom facilities in the Country Store during the period the resident was housed there.
Resident Placed in Room Without Call Light
Penalty
Summary
A deficiency occurred when a resident was placed to sleep on a mattress on the floor in a room known as the Country Store, located in the secure memory care unit, which did not have a functioning call light system. Multiple staff interviews confirmed that the resident spent at least one night in this room without access to a call light, as all regular rooms in the unit were occupied. Staff were aware of the lack of a call light in the Country Store but reported having no other options for the resident's accommodation at that time. Facility management was informed of the situation, and staff were instructed to resolve the room issue the following morning. Direct observation confirmed the absence of a call light in the Country Store.
Failure to Limit PRN Anti-Anxiety Medication and Inadequate Indication for Antipsychotic Use
Penalty
Summary
The facility failed to ensure that PRN anti-anxiety medication was limited to 14 days for a resident and did not provide adequate indication for the use of an antipsychotic for another resident. Resident #49 was prescribed Diazepam 2 mg daily for anxiety, with an additional PRN dose of 1 mg as needed. This PRN order was renewed every 14 days for over eight months without documented signs of anxiety during the times the PRN dose was administered. The pharmacy recommended a gradual dose reduction, but the physician did not provide documentation to support why a reduction was contraindicated, nor did they document the resident's behaviors or response to the medication. Resident #99 was involved in physical altercations with other residents and was prescribed Sertraline for anxiety, which was later increased without documented signs of anxiety or depression. The facility failed to monitor and document the side effects of the medication as ordered by the physician. After another altercation, Seroquel was prescribed for sundowning with agitation, but the facility did not document the behaviors leading to this decision. Staff interviews revealed a lack of consistent documentation of behaviors and a lack of understanding that staff could question physician orders for psychotropic medications.
Deficiency in Dietary Management and Oversight
Penalty
Summary
The facility failed to employ a Certified Dietary Manager to oversee the food and nutrition services, which increased the risk of negative outcomes for all residents receiving nutritional services. During an initial observation of the kitchen, several concerns were identified, including issues with employee hygiene supplies, soiled kitchen equipment, improper food storage, cleanliness of the dietary department, and pest control. These observations were linked to deficiencies noted under F812, F908, and F925. Interviews with staff revealed that the facility relies on a contract dietician who visits every other week and is available for consultation. However, the dietician has not met with the dietary manager, who has been in the position for about three months and is still completing a Certified Food Manager program. The dietary manager's lack of certification and the absence of direct collaboration with the dietician were highlighted as contributing factors to the deficiency. The facility had to promote internally for the Dietary Manager position due to hiring challenges, and the dietician primarily works with the Interdisciplinary Team (IDT) rather than directly with the dietary manager.
Sanitation and Food Safety Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen and dietary storage areas, as observed during a survey. Key issues included the absence of paper towels and soap at handwashing stations, grease and dirt buildup on kitchen equipment, and the presence of mouse droppings in storage areas. Additionally, food items in the walk-in cooler and freezer were not labeled or dated, and there was a lack of appropriate pest control measures. These deficiencies were noted during multiple observations over several days, indicating a pattern of non-compliance with sanitary standards. Furthermore, kitchen staff were observed not wearing beard coverings while serving and preparing food, despite having facial hair. Interviews with staff revealed that beard coverings were not available, and there was a lack of adherence to food labeling and dating protocols. The facility's cleaning logs showed infrequent cleaning of the storeroom, and the facility's policy on food storage was not being followed, as evidenced by the uncovered, unlabeled, and undated food items in the refrigerator and freezer.
Kitchen Cleanliness and Pest Control Deficiencies
Penalty
Summary
The facility failed to effectively identify, correct, and monitor quality-deficient practices related to kitchen cleanliness and pest control, as observed during a survey. During an initial tour of the kitchen, several issues were noted, including grease and dust buildup on stove burner handles, grease accumulation under the grill, and a nonfunctional oven being used for storage. Additionally, the microwave was found with debris and dirt, and a puddle of water was present on the kitchen floor without a wet floor sign. Mouse droppings were observed in the food storage and chemical storage areas, and a bag of cake mix was found with a hole and mouse droppings inside. Items in the walk-in refrigerator were not labeled or dated, and several pieces of kitchen equipment were nonfunctional. Interviews with staff revealed a lack of awareness regarding the frequency of pest control visits and acknowledgment of ongoing issues with mice in the kitchen. Despite the facility's Quality Assurance and Performance Improvement (QAPI) program identifying kitchen issues since April, the current concerns were not detected through their monitoring or oversight. The facility's Quality Assurance and Performance Plan, reviewed in January 2024, emphasized prioritizing topics for Performance Improvement Projects (PIPs) based on current needs, yet the existing deficiencies in the kitchen were not adequately addressed.
Pest Control Deficiency in Facility
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by multiple observations of pests in various areas, including the kitchen, 200 and 300 halls, and a resident's room. An ant was observed near a resident's recliner, and dead insects were found scattered on the floor in the 300 hallway. Beetles were seen crawling in the hallway and near exit doors in the 200 unit. Staff interviews confirmed the presence of ants and other bugs, with one staff member acknowledging a bug problem, particularly with ants. Another staff member noted that bugs entered through screenless windows, but was unaware of any actions taken by the facility to address the issue. During a kitchen tour, mouse droppings were found in the dry food storage and chemical storage areas, with a significant amount along the floor perimeter. A plastic tote containing cake mix had a bag with a hole chewed through it, and mouse droppings were present at the bottom of the tote. Although mouse traps were placed in the kitchen, a staff member admitted awareness of the mice issue and mentioned that the pest control company visited monthly. However, facility records showed that pest control services had not been completed since March 2024, despite a policy stating the facility should maintain an ongoing pest control program.
Failure to Invite Residents to Care Plan Meetings
Penalty
Summary
The facility failed to invite residents to participate in their care plan meetings, affecting four out of 43 sampled residents. Resident #89 reported that although staff mentioned care meetings, they were never conducted, and there was no evidence in the electronic health record (EHR) of any invitations. Resident #63 expressed a desire to attend care plan meetings but had not been invited since December of the previous year. Similarly, resident #21 had not attended a care plan meeting in eight or nine months, despite wanting to participate. Resident #91 was unaware of what a care plan was and had never been invited to a meeting. A staff member confirmed that care plans are updated as needed, but acknowledged that the facility was behind on scheduling these meetings. The EHR for resident #91 showed no record of invitations or participation in care conferences since their admission. Staff interviews revealed that social services were responsible for coordinating and inviting residents to these meetings, but there was a backlog in care plan scheduling.
Deficiencies in Maintaining a Clean and Sanitary Environment
Penalty
Summary
The facility failed to maintain a clean and sanitary environment for several residents, as evidenced by multiple observations and interviews. Resident #89 reported bugs in her room, and staff provided bug spray instead of addressing the root cause. A large spider was observed in a common area, and staff noted small bugs on the floor. Resident #63's bathroom was observed to be dirty, with a brown build-up stain and a urine smell, and remained in the same condition over several days. Resident #32's room and shared bathroom were found with debris, a soiled brief, stained slippers, and beetles, despite residents reporting the issue to staff multiple times. Staff interviews revealed a lack of awareness or action taken to resolve the bug problem. The 300 hallway and resident rooms for residents #39 and #65 were also not consistently cleaned. Observations noted a urine smell, water damage, and debris on the floors. Bug remnants were found in the hallway, and dark fabric debris and sticky floors were noted in resident #65's room. Staff interviews indicated that housekeeping staff were assigned daily cleaning tasks, but there was a lack of communication and follow-up on the bug issues. The facility's cleaning policy required regular disinfection, but the observed conditions suggested non-compliance. Despite checklists indicating cleaning was completed, the persistent issues pointed to deficiencies in maintaining a sanitary environment.
Improper Disposal of Discontinued Medications
Penalty
Summary
The facility failed to ensure the proper disposal or destruction of discontinued medications for two residents who had been discharged. During an observation of the medication cart, an Insulin Aspart FlexPen labeled for a resident who was discharged six days prior was found. Additionally, three Insulin Lispro KwikPens labeled for another resident who was discharged over two weeks earlier were also discovered. Further inspection of the medication cart revealed several insulin and Victoza pens with partially removed, illegible, or no labels. A staff member interviewed was unaware of the procedure for handling unused insulin or Victoza pens and speculated that they belonged to discharged residents. The facility's policy indicated that discontinued medications should be destroyed or returned to the issuing pharmacy, but this was not adhered to in these instances.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent, resulting in an error rate of 11.54 percent for two of the 43 sampled residents. During a medication administration observation, staff member G administered incorrect dosages and types of medications to resident #37. Specifically, the resident received vitamin D3 at a dosage of 20 mcg instead of the ordered 25 mcg, and a multivitamin with minerals instead of the prescribed multivitamin without minerals. These discrepancies were identified upon reviewing the resident's Medication Administration Record (MAR) dated 7/17/24. In another instance, staff member G administered a cranberry tablet to resident #309 without a specified dosage, as the MAR only indicated a daily cranberry tablet order without dosage details. During a follow-up interview, staff member G acknowledged the errors in administering the vitamin D3, cranberry tablet, and multivitamin. The facility's policy on medication orders requires that orders include the name, strength, dosage, and frequency of administration, which was not adhered to in these cases.
Failure to Accommodate Resident's Wheelchair Needs
Penalty
Summary
The facility failed to accommodate the needs and preferences of a resident, leading to a deficiency in maintaining the resident's highest practicable level of functioning. The resident, who was observed attempting to reposition himself multiple times using his hands and forearms, was experiencing pain in his left wrist. This pain was documented in the nurse progress notes, and it was noted that the resident was favoring his wrist and not using it as much. A provider identified that the motorized wheelchair's armrest did not accommodate the length of the resident's left forearm, necessitating frequent position changes. An x-ray revealed a chronic ligament tear and early advanced collapse of the resident's left wrist. The Interdisciplinary Team (IDT) identified the root cause of the wrist pain as the resident pushing himself back in the wheelchair. The intervention was to have therapy evaluate the armrests and educate the resident on alternative repositioning methods. However, the occupational therapy notes indicated a delay in follow-up with the wheelchair provider for readjustment. Communication with the wheelchair provider was initiated, but there was no further written communication provided to confirm the evaluation of the wheelchair. This lack of timely action contributed to the deficiency in addressing the resident's needs.
Failure to Protect Residents from Abuse by Staff Member
Penalty
Summary
The facility failed to protect residents from abuse by a staff member, identified as NF4, involving two residents. Resident 304 reported that NF4 was rough during a transfer and used the term 'diaper' during incontinence care, which she found degrading. She also experienced right knee and leg pain following the incident and expressed a desire not to have NF4 care for her anymore. Resident 305 similarly reported that NF4 was rough during care and ignored his expressed needs, leading him to prefer not to receive care from NF4. The incident was reported to the State Survey Agency, and NF4 was immediately suspended pending investigation. The investigation confirmed the allegations of abuse. NF4 refused to provide a statement and did not return to work at the facility. Other residents on the unit were interviewed, and none reported issues with NF4. The incident was discussed in the facility's QAPI meeting.
Failure to Identify and Document Concave Mattress as a Restraint
Penalty
Summary
The facility failed to identify a concave mattress as a potential restraint for a resident and did not complete the necessary risk assessment, obtain written consent, or implement monitoring procedures. During an observation, a concave mattress was noted on the bed of a resident who was not present at the time. Interviews with staff members revealed that the mattress was used to prevent the resident from falling out of bed, as the resident had a history of falls and injuries related to a fracture from a fall at home, medication use, and changes in blood pressure. Despite these measures, the resident's medical record lacked documentation of a restraint risk assessment, consent, or monitoring for the use of the concave mattress prior to the survey date.
Failure to Provide Effective Foot Care for Diabetic Resident
Penalty
Summary
The facility failed to provide effective foot care for a diabetic resident, leading to a deficiency. During an observation and interview, a resident reported that her toenails were very long and curling, and she could not recall them being cut since her admission to the facility. Staff interviews revealed confusion about responsibility for scheduling podiatry appointments, with one staff member expressing discomfort in cutting the resident's nails due to her health conditions. Another staff member indicated that appointments should be documented in the resident's care plan, but a review of the resident's electronic health record showed no documentation of podiatry needs or appointments.
Trip Hazard and Hazardous Material Exposure in LTC Facility
Penalty
Summary
The facility failed to identify and mitigate a trip hazard by using a twin-size scoop mattress as a bedside fall mat for a resident. During an observation, the mattress was noted to be placed next to a resident's roommate's bed, and the resident reported that the mat was often moved to their side of the room, obstructing access to the restroom. The resident also mentioned witnessing a staff member trip over the mat, although no injury occurred. A staff member acknowledged the use of the mattress for fall prevention but expressed concerns about its size and difficulty in moving it, which could potentially lead to accidents. Additionally, the facility failed to protect a resident from hazardous materials by allowing them to keep a can of bug spray in their room. The resident reported informing the staff about bugs in the room, and management provided the bug spray for use. The spray was observed on the resident's dresser during multiple observations. The Safety Data Sheet for the spray indicated potential health risks, including skin and respiratory irritation, if not handled properly. Despite these risks, the facility permitted the resident to retain the spray in an accessible location.
Deficiencies in Dietary Management and Kitchen Sanitation
Penalty
Summary
The facility administration failed to hire and employ a Dietary Manager with the appropriate competencies and skills to manage the food and nutritional services effectively. Observations during a kitchen tour revealed several deficiencies, including a staff member serving food without a beard covering, grease and dust buildup on stove handles, and nonfunctional kitchen equipment. Additionally, there were mouse droppings in the food and chemical storage areas, and a bag of cake mix was found with a hole and mouse droppings inside. Items in the walk-in refrigerator were not labeled or dated, and there was a puddle of water on the kitchen floor without a wet floor sign. Interviews with staff members revealed that the facility dietitian did not schedule regular consultations or work directly with the dietary manager, who was promoted from within due to hiring challenges and had not completed a Certified Food Manager program. The facility had a contract dietitian who was available for consultation but had not met the dietary manager. A grievance was filed regarding bugs in the food, and staff acknowledged issues with mice in the kitchen. The facility had identified kitchen issues and included them in their QAPI process, with the last walk-through noting only minor issues.
Infection Control and Maintenance Deficiencies
Penalty
Summary
The facility failed to ensure enhanced barrier precautions were followed during wound care and medication administration through a feeding tube for a resident. During an observation, a staff member did not wear a gown while providing wound treatment to a resident's sacral pressure ulcer, incorrectly believing that gowns were only necessary for tube feedings and catheters. The same staff member also failed to wear a gown while administering medication through a feeding tube, acknowledging the oversight when questioned. Interviews with other staff members revealed that the facility had recently hired a new infection control preventionist who had conducted some observational audits. However, there was a discrepancy in understanding when gowns should be worn, despite ongoing training on enhanced barrier precautions. Additionally, the facility failed to repair a worn recliner in a resident's room, resulting in an uncleanable surface. Observations noted the recliner had wearing, tearing, and scratches, with material flaking off onto the floor. Despite the visible damage, no maintenance requests were provided by the end of the survey period. A staff member expressed uncertainty about the recliner's repair status and suggested it should be discarded, indicating a lack of communication or action regarding maintenance issues.
Failure to Maintain Kitchen Equipment
Penalty
Summary
The facility failed to ensure the safe and proper operation of essential kitchen equipment, including the oven, dessert refrigerator, cook's refrigerator, and ice machine. During an initial tour, it was observed that there were no paper towels in the dispensers near the sinks in the serving area, and the ice machine was warm with no ice present. The dessert refrigerator was also warm, containing several cans of unopened V8 juice. On a subsequent observation, the same issues persisted, with the addition of the ovens below the gas stove being non-functional and used for storage, and a sink behind the steam table having a plugged drain with standing water. Interviews with staff revealed that the equipment had been non-functional for an extended period, with the ice machine being the most recent to fail. Staff members indicated that issues were reported through the TELS system, but the maintenance logs from January 2024 to the present did not document which equipment was non-functional or any repairs made. This lack of documentation and unresolved equipment issues had the potential to affect any resident receiving food from the kitchen.
Latest citations in Montana
A dependent resident admitted post-surgery with intact but vulnerable skin and MASD risk developed significant bilateral buttock MASD and a sacral pressure injury that progressed from deep tissue injury to Stage III and then to a large unstageable ulcer with odor and purulent drainage. Facility records showed incomplete and missing weekly skin/wound assessments during the period when the wound worsened, despite a care plan calling for skin evaluations, turning/repositioning, CNA skin inspections, and monitoring of nutrition. Staff interviews revealed they were frustrated by the resident’s anxiety and behaviors, reported the sacral wound as facility-acquired, acknowledged the resident became obtunded on an intense opioid regimen, and stated they were unaware of excessive fluid intake and could not explain why the worsening wound and infection were not recognized or reported before the resident required hospital transfer for a severe sacral decubitus ulcer with associated infection.
Surveyors found that kitchen staff failed to properly label and date multiple food items stored in the walk-in cooler, including slimy sliced tomatoes, ground meat, sliced ham, roast beef, cheese, and strawberries. Staff reported that they sometimes picked moldy strawberries out of shipments and that moldy dinner rolls had been served and then collected from residents. These practices did not follow the facility’s written policy requiring labeling, dating, and monitoring of refrigerated foods so they are used by their use-by date or discarded, placing all residents at risk for foodborne illness.
The facility failed to submit required investigation findings to the State Survey Agency (SSA) within 5 working days for multiple abuse and elopement incidents. In one case, a resident kicked another resident’s feet, and in another, one resident kicked another in the legs while both were in wheelchairs; in both situations, the facility did not provide timely or, in one case, any investigative findings to the SSA. The facility also reported two separate elopement events for a resident but did not submit final investigation reports for either incident. A staff member reported that another staff member, who was absent during the survey, was responsible for SSA reporting, and confirmed the expectation to report all investigation results within 5 working days per facility policy.
Two residents were involved in a resident-to-resident abuse incident in which one resident kicked another multiple times while both were in wheelchairs, and although staff separated them and documented the event, the facility did not complete or document a formal abuse investigation, did not ensure ongoing protection from further confrontations, and did not report investigative findings to the SSA. In addition, several residents experienced multiple elopements, with documentation that one resident followed others out back doors and another exited through doors into a hospital area, yet the facility’s investigation files lacked clear timelines, comprehensive staff interviews, identification of information sources, and root-cause analyses of exit-seeking behavior. Staff interviews confirmed that while nurses submitted occurrence reports and SSA notifications and discussed root causes informally, management did not consistently document thorough investigations or root-cause findings as required by facility policy.
The facility failed to provide adequate supervision and effective elopement-prevention interventions for several cognitively impaired, exit-seeking residents who were known elopement risks. Despite assessments, care plans, anti-wandering devices, and door alarms, residents repeatedly exited through front and back doors without timely staff redirection or alarm response, and some elopements were not properly documented in the EHR. One resident with dementia and short-term memory loss was not care planned for elopement until after multiple attempts, and another resident with severe cognitive impairment left through sliding doors unnoticed. A resident with an anti-elopement alarm on her wheelchair repeatedly triggered the door alarm throughout the day, yet staff did not effectively respond, allowing her to exit unsupervised and fall on stairs, sustaining minor injuries.
The facility failed to provide meaningful, resident-centered activities for multiple dementia residents in the memory care unit, resulting in individuals sitting idle in dining and common areas, staring at blank or inappropriate televisions, sleeping in chairs, or wandering hallways without engagement. Activity sessions were canceled or not implemented as scheduled, and when paper activities like word searches were offered, only a few residents participated while others received no assistance, including a resident who repeatedly requested glasses and another who did not speak English. Sitters did not help residents with activities, and an activity staff member spent time on a computer and left the unit for other duties. Staff interviews revealed that management directed the limitation of music and physical activities, that residents were often left in bed because it was easier for staff, that floor staff did not conduct activities in the absence of the activity staff, and that the posted activity calendar, which included exercise, trivia, book club, and weekend "Resident Choice Day," was frequently not followed despite a policy requiring meaningful activities tailored to dementia residents.
A hospice resident with metastatic cancer and behavioral symptoms received multiple sedating medications, including quetiapine, hydrocodone, morphine, lorazepam, olanzapine, and prednisone, without thorough assessment for unnecessary drugs, duplicate therapy, or adverse consequences. Despite documented behavioral issues, falls, cognitive decline, and moderate to severe pain scores, staff reported no concerns with the medication regimen. The resident became increasingly sedated, was found unconscious with minimal response to painful stimuli, and was sent to the hospital, where documentation linked the clinical picture to disease progression and medication effects, including opioid use and possible steroid-induced psychosis.
A resident with a documented history of opioid-induced constipation and prior fecal impaction was admitted from the hospital, where providers had noted difficulty balancing opioid use and constipation medications. On admission, facility documentation characterized the resident as having normal stool and rarely needing laxatives. Over the following weeks, bowel records showed multiple days without a bowel movement, yet the MAR reflected no scheduled or PRN constipation medications given. Nursing notes documented no constipation despite absent bowel sounds, while subsequent hospital imaging revealed an extensive rectal stool burden concerning for stercoral colitis. Staff interviews confirmed that the prolonged absence of bowel movements was not reported, the resident received no PRN bowel medications, and there was no specific bowel and bladder management policy.
Staff failed to follow hand hygiene practices while caring for a resident with weeping, hot lower legs who had been started on antibiotics for cellulitis. One staff member removed TED hose from the resident’s weeping left leg and then immediately assessed the right leg without changing gloves or performing hand hygiene. Another staff member, after applying TED hose to the weeping leg while gloved, continued to handle the resident’s food, pillow, and personal items and answered a cell phone by placing her gloved hand into her pocket, all without changing gloves or performing hand hygiene, contrary to the facility’s hand hygiene policy.
The facility failed to protect residents from abuse when one resident without capacity to consent was found in a common area with another resident’s hand inside her brief, and the subsequent investigation did not include interviewing or assessing other residents who might have been affected. In a separate event, a resident shook his spouse’s head and later sprayed water in her face with a spray bottle when she was tired at dinner, causing her agitation, while both continued to share a room and she spent most of her time and slept in common areas due to ongoing behaviors between them, as reflected in her care plan.
Failure to Prevent and Manage Pressure Ulcer Leading to Severe Sacral Wound
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate prevention and treatment of pressure ulcers and to complete and document required skin and wound assessments for a dependent resident. The resident was admitted from a hospital with red skin on the right elbow, a left neck surgical laminectomy site, and a left shin abrasion, and was totally dependent on staff for bed mobility, transfers, dressing, toileting, personal hygiene, and bathing, and had a Foley catheter. Within six days of admission, weekly wound documentation showed the resident had developed bilateral buttock moisture-associated skin damage (MASD) of significant size. The resident was then hospitalized for confusion and hyponatremia, and hospital wound care documented a deep tissue pressure injury to the sacrum that evolved into a Stage III pressure injury with yeast. When the resident returned to the facility, the facility’s readmit screener documented MASD to the buttocks and a yeast rash to the buttocks and groin, but no sacral pressure injury. Subsequent facility wound documentation showed that a few days after readmission, the resident had scattered ulcerations with MASD to the buttocks and a Stage III pressure ulcer to the right medial lower buttock, and that orders for treatment were requested from the physician. By the following week, the weekly wound observation tool documented that the Stage III bilateral buttock wounds had merged into one large unstageable pressure ulcer with odor and moderate purulent drainage, indicating potential infection. During this same period, there were no documented skin/wound assessments for the week leading up to the resident’s transfer back to the hospital, and a staff member later stated she did not know where the assessments were or why they were not done, and could not explain why no one reported that the wound was worsening. The care plan listed multiple skin integrity problems and interventions, including skin evaluations, routine turning and repositioning, CNA skin inspections with routine care, monitoring nutrition, and weekly nurse skin evaluations, but did not specify task frequency for some interventions. Interviews further described staff awareness and handling of the resident’s condition and behaviors. A family member reported that staff were frequently frustrated by the resident’s constant need for attention and anxiety, and that he repeatedly educated management about the resident’s high anxiety and hyperfocus, and did not understand how staff could report spending so much time with the resident yet not recognize how sick he was with infection. A staff member stated the sacral wound was facility-acquired, that the resident became obtunded related to opioids, and that she was unaware of the resident’s excessive water intake until after a hospital stay. Another staff member who completed a readmission history and physical found the resident febrile, with therapy unable to mobilize him due to pain, and described the resident as heavily sedated on an intense pain regimen that predated his stay. This staff member stated there were many opportunities for improvement in nursing assessments and that the facility could not handle the resident’s complex psychiatric and pain needs. Ultimately, the resident was transferred to the hospital with a large sacral decubitus wound with purulent tissue, surrounding cellulitis, and radiologic evidence of a severe sacral ulcer with erosion nearly to the coccyx and associated abscess and necrotizing soft tissue infection.
Improper Labeling, Dating, and Handling of Refrigerated Food Items
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage practices when, during an observation of the walk-in cooler, multiple food items were found undated or unlabeled, contrary to the facility’s Food Safety Requirements policy. Specifically, two zip-lock bags of slimy, sliced tomatoes were not dated; a gallon zip-lock bag of ground meat was not labeled with the food type or date; and separate gallon zip-lock bags of sliced ham, sliced roast beef, and sliced cheese were all undated. In addition, a cup of sliced strawberries had no date. Staff interviews revealed that kitchen staff had observed mold on strawberries upon delivery and would usually attempt to pick out the molded strawberries, and another staff member acknowledged awareness of ongoing dating issues with refrigerated foods. A further interview indicated that moldy dinner rolls had been served on one occasion, prompting staff to retrieve the rolls from residents after service. The facility’s written policy required labeling, dating, and monitoring refrigerated food, including leftovers, so it would be used by its use-by date or frozen/discarded, but these requirements were not followed, placing all residents at risk for foodborne illnesses. No specific residents or their medical histories were identified in the report; the deficiency was described as affecting all residents through improper food labeling, dating, and handling practices in the kitchen and walk-in cooler.
Failure to Submit Abuse and Elopement Investigation Findings Within Required Timeframe
Penalty
Summary
The facility failed to submit investigation findings related to alleged abuse and elopement incidents to the State Survey Agency (SSA) within the required 5 working days for multiple residents. For one incident dated 1/24/26, a resident left her room and kicked another resident’s feet; the facility’s investigative findings for this event were not submitted to the SSA until 2/4/26, which was 11 days after the incident was reported. For another incident dated 3/20/26, one resident kicked another resident in the legs while both were in wheelchairs, with no injuries reported and immediate separation of the residents; review of records showed no evidence that the facility ever submitted investigative findings for this incident to the SSA. Additionally, review of the SSA reporting site showed that the facility made initial reports of elopement for a resident on 7/18/25 and 2/1/26 but did not submit final investigation reports within the required 5 working days. There were no final reports for either elopement incident. During an interview, a staff member stated that another staff member, who was out of the facility during the survey week, was responsible for reporting and submitting investigative findings to the SSA for abuse allegations. The same staff member confirmed the expectation that findings of any abuse allegation be reported to the SSA within 5 working days and acknowledged they could not provide investigative findings for the 3/20/26 incident. The facility’s written policy, reviewed and dated 7/15/25, required that results of all investigations of alleged violations be reported within 5 working days of the incident.
Failure to Investigate Resident Abuse and Elopements or Identify Root Causes
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and manage an allegation of resident-to-resident abuse and multiple resident elopements. In one incident, a resident in a wheelchair kicked another resident multiple times in the lower legs while both were at the nurses’ station. Nursing documentation noted the kicking and that there were no injuries, and the immediate response was to separate the residents. However, review of the facility’s abuse investigations for the relevant period showed no completed investigation related to this reported allegation of resident-to-resident abuse, and there was no documentation of investigative findings or that these findings were reported to the State Survey Agency. The facility also failed to protect the involved residents from further potential abuse. Nursing notes for both residents documented that, two days after the kicking incident, one resident was observed continually attempting to follow, communicate with, agitate, and argue with the other resident, and staff had to separate them twice. Staff communicated to others to monitor their interactions, but the notes showed that the residents continued to have problematic contact, indicating that the facility did not prevent further potential abuse between them. During interview, a staff member stated that another staff person was responsible for investigating and reporting abuse allegations, but that person was unavailable and no documentation could be produced to verify that an investigation had been completed or that results were reported to the state agency, despite facility policy requiring thorough investigation, protection of residents during the investigation, and reporting of results. The deficiency also includes failures related to multiple elopements by several residents. For one resident, an elopement investigation documented that the resident exited the facility, but the investigation lacked signatures, identification of information sources, and clear involvement of the email sender included in the file. A state abuse reporting entry indicated that this resident left through back doors, possibly following a volunteer or staff taking other residents to Mass, and was brought back by a Med-Surg nurse, but there was no documented root-cause analysis or explanation of why the elopement occurred or what interventions were implemented to prevent recurrence. Another resident eloped through doors leading into the hospital; the reportable incident was submitted to the SSA, but there were no nurses’ notes on the date of the elopement describing the event, and a note the following day only stated that the resident attempted to elope twice, reflecting incomplete contemporaneous documentation. For this same resident, the facility’s investigation of the elopement included only limited staff interviews and did not include interviews with CNAs or activity staff to establish a full timeline of the resident’s movements or to identify the root cause. A subsequent elopement by this resident into the hospital was documented in a nursing note, and the investigation consisted of an undated handwritten note stating that people came into the unit looking for someone in the hospital, left to go to Med-Surg, and the resident followed them out the door, with the door alarm functioning and the resident returning to the unit. There was no documented timeline, no detailed interviews, and no analysis of the effectiveness of elopement-prevention interventions. A third resident had multiple documented elopements over several months, with investigation files that often contained only brief summaries, incomplete checklists, or limited supporting documents such as bounds reports or invoices for a wander guard system. Across these events, the facility did not consistently document root-cause analyses or assessments of the resident’s exit-seeking behavior, and the record notes that this failure to identify and document root causes led to a fall with injury for this resident. Interviews with staff confirmed that the facility’s practice did not align with its stated expectations. One staff member reported that a former staff person had previously conducted incident investigations but had left months earlier, and that the expectation for investigations was to determine the root cause of incidents and monitor residents to ensure interventions were implemented. Another staff member stated that after each elopement, the nurse would file a report to the SSA and update the care plan, after which management was supposed to conduct a full investigation. A further interview indicated that nurses entered occurrence reports and submitted SSA reports to track elopements and that staff discussed root causes but did not maintain documentation of those analyses. These statements, combined with the incomplete and inconsistent investigation records, demonstrate that the facility did not carry out or document thorough investigations, root-cause analyses, or protective measures as required by its own abuse investigation and reporting policy.
Failure to Prevent Elopements and Respond to Anti-Wandering Alarms
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and effective interventions to prevent elopements for multiple residents identified as at risk for wandering, despite existing assessments and care plans. Staff reported that residents at risk for elopement were identified by the MDS nurse on admission and quarterly, and that anti-wandering devices and door alarms were in place, particularly at the front door. However, staff also indicated that wander guard bracelets could be applied without formal assessment, and that information about elopement risk was communicated via paper “brain” sheets. The facility had a written SBAR and procedure for anti-wandering door alarms, including immediate resident location checks and following an elopement procedure, but the report shows these processes were not effectively implemented. One resident with a documented elopement risk and dementia was care planned to have an anti-wander device on her wheelchair and to be involved in activities and redirected when she attempted to exit. She eloped on at least two occasions: once when she went through the first set of doors and was found in a corridor by another resident, and another time when she exited through back doors, apparently following others going to Mass, with no alarms triggered. Her care plan documentation was inaccurate regarding the presence of a wander guard door in 2024, and there was no nursing documentation of the February elopement in her electronic health record. Another resident with severe cognitive impairment (BIMS score of 3) and an elopement risk care plan that included redirection, diversional activities, and ensuring door alarms were activated, was able to get out between the sliding front doors when someone was entering or exiting, and no one saw her leave, contrary to the care plan interventions. A further resident with dementia and short-term memory problems was identified as at risk for elopement, yet his elopement care plan and interventions were not initiated until after he had already eloped twice in one afternoon through different doors. He later eloped again, but the corresponding nursing note was not provided. Another resident, described as exit seeking and very independent with behavioral issues toward staff, had an anti-elopement alarm device on her wheelchair that sounded as she approached the door and had been near the door setting off the alarm throughout the day. Despite this, she was able to push open the main entrance sliding doors, exit, and then fall while attempting to walk down stairs, sustaining an abrasion and bruising and requiring hospital evaluation. Staff interviews indicated that interventions such as 1:1 monitoring, taking her outside, and diversional tasks were used, and that elopements were tracked via occurrence reports and state submissions, but the facility failed to identify the need for continuous one-on-one monitoring for this resident, failed to respond appropriately to the anti-elopement door alarm, and failed to prevent her unsupervised exit and subsequent fall. Activity staff also reported that, after a staffing reduction, there were no organized activities after 5 p.m., despite prior recognition that increased monitoring and activities during late afternoon hours were needed for an elopement-risk resident.
Failure to Provide Meaningful Activities for Dementia Residents in Memory Care Unit
Penalty
Summary
The deficiency involves the facility’s failure to provide meaningful, resident-centered activities to meet the needs of multiple residents with dementia in the memory care unit. Surveyors observed residents sitting in dining and common areas without any activities, including a resident with a BIMS score of 0 repeatedly scratching her arms while staring at a turned-off television, and another resident wandering the unit and running into walls. On another observation, the scheduled activities were canceled due to weather, and the activity staff member present was working on care plans on a computer while residents sat with newsletters in front of them, many staring at the floor or sleeping. Only some residents participated in the offered activities, while others, including residents with severely and moderately impaired memory, did not participate and were not engaged. During the same observation period, residents were given a word search activity, but only a few actively worked on it. Sitters, who were present to watch and redirect residents, sat at the tables and did not attempt to assist residents with the activity. One resident repeatedly stated she needed her glasses to see the paper, but no staff obtained her glasses. A resident who did not speak English sat staring down the hall without engagement, and another resident with severe cognitive impairment wandered the hall. The activity staff member stated she had other duties in another unit and left, and later that evening, surveyors observed one resident sleeping in a recliner and another staring at a wall while cartoons played on the television. Interviews with staff revealed that activities in the memory care unit were limited and often not implemented as scheduled. The activity staff member reported she was instructed by management to avoid music and physical activities because staff believed these would cause residents to become agitated, and that she was told to limit activities to calming options only. She also stated that residents were often left in bed and not taken to activities because it was easier for staff, and that floor staff did not provide activities when she was not present, preferring residents to sit quietly. Other staff confirmed that activities usually did not occur in the memory care unit, that activities observed during the survey were a show for surveyors, and that the activity calendar was not followed. The memory care activity calendar showed “Resident Choice Day” on all weekends and listed trivia, exercise/stretching, and book club on weekdays, while the facility’s activities policy required activities to enhance well-being, physical activity, cognition, and to provide meaningful activities for residents with dementia.
Failure to Assess Hospice Resident’s Polypharmacy and Sedation Risk
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s drug regimen was free from unnecessary medications and thoroughly assessed for sedation, duplicate therapy, and adverse consequences. A hospice resident with metastatic cancer, delirium, psychosis, and impulsive, intermittently aggressive behavior was receiving multiple medications including antipsychotics, opioids, benzodiazepines, and a steroid. Hospice staff discontinued some medications and added morphine and lorazepam, while the resident also continued on quetiapine, hydrocodone, prednisone, and later received a one-time dose of olanzapine. Facility staff A and B reported that they had no concerns with the resident’s medications despite the combination of psychotropic and sedating drugs. The resident had been ambulatory on arrival to the facility but became weaker with multiple falls, nonsensical and incoherent speech, and combative and unsafe behavior. One-to-one supervision was initiated due to impulsivity and aggression, and staff questioned whether pain contributed to the aggressive behavior. The resident’s pain scores documented on the Medication Administration Record over three days showed moderate to severe pain levels (5/10, 3/10, and 7/10), while the resident continued to receive multiple sedating medications, including quetiapine every eight hours, hydrocodone three times daily, lorazepam as needed every four hours, morphine as needed every four hours, and prednisone daily. On the day before transfer to the hospital, the resident received olanzapine, prednisone, hydrocodone, two doses of lorazepam, and morphine; on the day of transfer, the resident received lorazepam, morphine, and prednisone. When a family member arrived at the facility, they found the resident unconscious with minimal response to painful stimuli and appearing sedated, and they requested transfer to the hospital. The family reported the resident had been more sedated at the facility lately, and the emergency room provider reportedly told the family the resident had an overdose of medications. Hospital documentation noted altered mental status, hypoxia, and that the resident’s dementia and chronic encephalopathy may have been exacerbated by disease progression and opioid use, possible steroid-induced psychosis, and electrolyte imbalance. The facility did not identify or address the resident’s medication regimen as a contributing factor to sedation or assess for duplicate therapy and adverse consequences prior to the resident’s transfer.
Failure to Monitor and Treat Constipation in Resident With Opioid-Induced Constipation History
Penalty
Summary
The facility failed to monitor and manage constipation for a resident with a known history of opioid-induced constipation and prior use of constipation medications. Hospital records showed the resident had been admitted with a 9.6 cm fecal impaction and that the hospital physician documented the resident could go up to five days without a bowel movement, likely due to opioid use, and was working on balancing opioid-induced constipation with constipation medications. Upon admission to the facility, the Admit/Readmit Screener documented that the resident had normal formed stool and rarely or never depended on laxatives, despite this history. Facility bowel documentation later showed gaps in bowel movements, including no bowel movement for several days. Review of the Medication Administration Record for March and April showed the resident did not receive any scheduled or PRN constipation medications during the stay. Bowel documentation indicated no bowel movement from 3/29 to 4/3, followed by diarrhea on 4/4 and a putty-like stool on 4/5. A nursing progress note on 4/6 documented a flat, non-tender abdomen with no bowel sounds and no constipation, while hospital records from the same date, after readmission, showed an extensive stool burden distending the rectum to 8.8 cm with findings concerning for stercoral colitis. Staff interviews revealed that no one reported the resident had gone six days without a bowel movement, the resident had gone without any PRN bowel medications, and the facility did not have a policy specific to bowel and bladder management.
Failure to Perform Hand Hygiene During Wound and Skin Care
Penalty
Summary
Facility staff failed to ensure proper hand hygiene during care of a resident with suspected infected lower extremities. During an observation, two staff members entered the room of a resident who had reported weeping and hot lower legs. One staff member removed the TED hose from the resident’s left leg, noted that the leg was hot to the touch and weeping edema fluid, then moved directly to the right leg, removed the TED hose, and assessed that leg without changing gloves or performing hand hygiene between contact with the weeping left leg and the intact right leg. This same staff member later stated she believed she had completed all hand hygiene opportunities but realized, when questioned, that she had moved from one leg to the other without performing hand hygiene. The resident had been started on Cipro for cellulitis on the morning of the observation. A second staff member returned to the room with new TED hose and socks, donned gloves, and assisted with applying the TED hose. This staff member applied TED hose to the resident’s left leg, observed weeping fluid from the skin, and then proceeded to clean up the room while still wearing the same contaminated gloves. While gloved, she touched the resident’s food on the bedside table, handled the resident’s pillow and placed it on the chair where the resident was sitting, and put her gloved hand into her clothing pocket to turn off her ringing cell phone. She did not perform hand hygiene or change gloves after contact with bodily fluids and before touching other items in the room. After leaving the room, she stated she had not thought about performing hand hygiene after finishing application of the TED hose. The facility’s hand hygiene policy required hand hygiene after handling contaminated objects, when moving from a contaminated site to a clean body site during resident care, and after handling items potentially contaminated with blood or bodily fluids.
Failure to Protect Residents From Sexual and Physical Abuse by Other Residents
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from abuse, including sexual and physical abuse, by other residents. In one incident, a resident without capacity to consent was found in a common area with another resident’s hand inside her brief up to the wrist. Staff immediately separated the residents, and the incident was reported to the State Survey Agency; however, the facility’s investigation did not include interviewing or assessing other residents who might have been present or potentially affected by similar sexual abuse incidents. A staff member also reported that the incident was initially reported under the wrong license type because they were unaware the facility held both an adult day care and a skilled nursing facility license. In a separate incident, a resident became upset with his spouse, also a resident, during dinner and shook her head to wake her, then later sprayed water in her face with a spray bottle after staff had intervened and moved her to the nurses’ station. The spouse became agitated by these actions. Observations showed that the couple continued to share a room, with both residents’ nameplates and belongings present. Staff interviews indicated that the spouse who was the target of the behavior was usually kept out of the room and spent most of her time and slept in common areas or by the nurses’ station due to ongoing behaviors between the two. The care plan for the spouse reflected that she was not to be in the room when her husband was present unless both wanted to be there, and staff were to intervene if yelling occurred, based on the prior incident of head shaking and use of the spray bottle.
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