BRENDAN HOUSE
Non profit - Corporation
110 Beds
Independent
Data: November 2025
Trust Grade
35/100
#25 of 59 in MT
Photo by Logan Health Brendan House
Photo by Logan Health Brendan House
Photo by Logan Health Brendan House
1 / 5 photos
Last Inspection: July 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Brendan House in Kalispell, Montana, has a Trust Grade of F, indicating significant concerns about the facility's performance. It ranks #25 out of 59 nursing homes in the state, which places it in the top half, but the low trust grade suggests serious issues. The facility is worsening, with the number of reported issues increasing from 8 in 2024 to 16 in 2025. Staffing is a strength, receiving a perfect score of 5/5 stars, and turnover is lower than the state average at 47%. However, the facility has faced $44,005 in fines, which is concerning and suggests compliance problems. Specific incidents include a failure to prevent severe weight loss in a resident and not following through on weekly weight checks, which could impact nutrition. Additionally, there was a serious issue where a resident developed a pressure ulcer due to inadequate care and positioning. While staffing is strong, these findings highlight significant weaknesses in resident care and oversight.
- Trust Score
- F
- In Montana
- #25/59
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 47% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ○ Average
- $44,005 in fines. Higher than 58% of Montana facilities. Some compliance issues.
- Skilled Nurses ✓ Good
- Each resident gets 84 minutes of Registered Nurse (RN) attention daily — more than 97% of Montana nursing homes. RNs are the most trained staff who catch health problems before they become serious.
- Violations ⚠ Watch
- 32 deficiencies on record. Higher than average. Multiple issues found across inspections.
35/100
Top 42%
Review needed
8 → 16 violations
★★★☆☆
3.0
Overall Rating
★★★★★
5.0
Staff Levels
★★★☆☆
3.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 8 issues
2025: 16 issues
The Good
-
5-Star Staffing Rating · Excellent nurse staffing levels
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in staffing levels, fire safety.
The Bad
3-Star Overall Rating
Near Montana average (3.0)
Meets federal standards, typical of most facilities
Staff Turnover: 47%
Near Montana avg (46%)
Higher turnover may affect care consistency
Federal Fines: $44,005
Above median ($33,413)
Moderate penalties - review what triggered them
The Ugly 32 deficiencies on record
4 actual harm
Jul 2025
16 deficiencies
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Deficiency F0692
(Tag F0692)
A resident was harmed · This affected 1 resident
Based on observation, interview, and record review, the facility failed to prevent a severe weight loss in 1 (#5); and the facility failed to complete weekly weights for four weeks, on a new admission...
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Based on observation, interview, and record review, the facility failed to prevent a severe weight loss in 1 (#5); and the facility failed to complete weekly weights for four weeks, on a new admission for 1 (#87) of 6 sampled residents for nutrition. Findings include:1. During an interview on 7/16/25 at 3:13 p.m., staff member D stated all physicians were notified when a resident was brought to NAR (Nutrition at Risk). Staff member D stated she could not write nutrition orders, but she could order supplements. Staff member D stated weights were supposed to be obtained the first weekend of the month. Staff member D stated she pulled reports on resident weights the following week. Staff member D stated the staff also sent a message if the resident had weight loss. Staff member D stated resident #5 was being followed by NAR, was receiving chocolate glucose control supplement, and Juven. Staff member D stated resident #5 had a significant decline related to progressing dementia. Staff member D stated care plans were updated quarterly, annually, and on admission. Staff member D stated if the care plans needed updated between the quarterly, annually, or on admit, it was the responsibility of the RCM (Resident Care Manager). Staff member D stated she was not involved in QAPI but stated she has been working on a new cycle of nutrition with the kitchen.
During an observation on 7/16/25 at 5:15 p.m., resident #5 was in the dining room for evening meal.
During an observation on 7/17/25 at 7:32 a.m., resident #5 was in the dining room for morning meal. At 7:55 a.m. the resident was served coffee. At 8:01 a.m. the resident was served his food, ate independently, and appeared to be eating slowly.
During an interview on 7/17/25 at 8:51 a.m., staff member E stated resident #5 was supposed to eat in the unit dining room. Staff member E stated the resident was resistant to getting out of bed. Staff member E stated the resident’s daughter wanted him up for meals. Staff member E stated the resident was previously a one to one for supervision while eating but was now under in-sight supervision only in the dining room. Staff member E stated the dietician did bring up weight loss as a concern. She stated the resident had some problems eating and swallowing. Staff member E stated the resident had speech therapy because of difficulty swallowing. Staff member E stated the resident was doing much better with eating and feeding himself when he was up out of bed and in the dining room.
During an interview on 7/17/25 at 9:25 a.m., staff member MM stated resident #5 was supervised for meals. Staff member MM stated the residents’ meals were in between minced (finely chopped) and moist (foods that are soft and moist) diet textures. Staff member MM stated the resident used to be a one-to-one assist for meals but now was in sight supervision while in the dining room. Staff member MM stated the resident was working with Speech Therapy.
During an interview on 7/17/25 at 10:01 a.m., Staff member B stated the residents were assessed on admission for nutrition concerns. Staff member B stated the dietitian was involved to evaluate interventions, implement interventions, communicate with family, and educate the staff.
Review of resident #5’s weight record showed the resident weighed 132 lbs., on 6/9/25 and 120 lbs., on 7/12/25, which is a 9% severe weight loss in one month.
Review of resident #5’s Nutrition/Dietary Progress Note, dated 6/10/25, showed staff member D was “unable to meet with the resident due to the flooring crew blocked the room. The resident was added to the NAR program due to severe weight loss in three months.”
Review of resident #5’s Nutrition/Dietary Progress Note, dated 6/23/25, showed staff member D and staff member E met and discussed the resident’s worsening pressure wound to his right foot. The plan was to add Juven meal supplement two times daily for wound healing.
Review of resident #5’s Nutrition/Dietary Progress Note, dated 6/24/25, showed the resident was to have weekly weights. The resident was followed due to malnutrition diagnosis.
Review of resident #5’s Nutrition/Dietary progress note, dated 7/10/25, showed the resident required supervision and cueing during meals. The resident was documented as nutrition at risk (NAR) and was in the program due to a malnutrition diagnosis and wounds.
2. During an observation on 7/14/25 at 4:15 p.m., resident #87 was lying in bed with oxygen on. Resident #87 appeared thin and frail. Resident #87’s skin color was pale. Three unopened sugar free Boost containers were sitting by the television.
During an interview on 7/15/25 at 8:08 a.m., resident #87 stated he was terminal and had a decrease in his appetite, but the facility was providing him with Boost at mealtimes. Resident #87 stated he does not always drink them.
During an interview on 7/16/25 at 3:10 p.m., staff member D stated all residents who were new admissions were to be weighed weekly for four weeks to help establish a baseline weight. Staff member D stated the weights were documented in the medical record. Staff member D stated sometimes residents would refuse to be weighed but the refusal should also be documented in the medical record.
Review of resident #87’s weight documentation from 6/27/25 to 7/17/25, showed a weight of 173.4 pounds on 6/27/25. No other weights were documented in resident #87’s electronic medical record.
Review of a facility document titled, “Weight/Nutrition at Risk, BH320,” with an effective date of 3/2025, showed:
“Policy
1. All patients/residents will be weighed on admission… and weights will be obtained weekly x 4 weeks and then monthly thereafter…”
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to provide dignity and privacy for a resident being transported to the shower room for 1 (#53); and failed to provide dignity an...
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Based on observation, interview, and record review, the facility failed to provide dignity and privacy for a resident being transported to the shower room for 1 (#53); and failed to provide dignity and privacy for a resident in a dining room without bottoms on, with a catheter, and full catheter bag showing, for 1 (#2) of 3 sampled residents for dignity. This deficient practice resulted in resident #53 feeling embarrassed. Findings include:1. During an observation on 7/15/25 at 8:32 a.m., resident #2 was observed napping in the dining room, in a manual wheelchair, sitting on a chuck (disposable under pad). Resident #2 was facing the dining room and the unit entrance. Resident #2 had her clothing bottoms below her knees. Her catheter was visible, and the full catheter bag was facing outward, without a privacy cover on the outer side. Other residents and several staff were present. Staff weren't addressing the resident's dignity concerns for the visible catheter bag without the cover.
During an interview on 7/17/25 at 10:58 a.m., staff member F stated she had been diligently trying several approaches to have resident #2 agree to put her pants on. Staff member F stated that eventually, resident #2 was taken to her room, she used a grab bar to stand, and her pants were pulled up.
2. During an observation on 7/16/25 at 9:02 a.m., staff member M entered resident #53’s room with a white shower chair. Resident #53 was in a hospital gown. Resident #53 was assisted to the shower chair, and he sat down. Resident #53’s back and buttocks were exposed and uncovered while in the shower chair. Staff member M wheeled the shower chair out of resident #53’s room and out past the dining room, where multiple residents and staff were sitting. Resident #53’s back and buttocks were visible to others as he was wheeled past the dining room. The staff member did not attempt to cover the resident's buttocks or back.
During an interview on 7/16/25 at 9:30 a.m., staff member M stated residents should be fully covered before leaving their rooms for a shower or bath. Staff member M stated, “I did not check to make sure he (#53) was not exposed. I should have.”
During an interview on 7/16/25 at 1:07 p.m., resident #53 stated he was upset and embarrassed that he was exposed to staff and other residents on his way to the shower.
Review of a facility policy titled, “Resident Rights and Responsibilities, BHSS907,” with an effective date of 2/2025, showed:
… “1. While at [Facility Name], a resident has a right to:
… F. Privacy …”
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
Based on interviews and record review, the facility failed to ensure the medical provider was notified of a resident's severe weight loss, for one (#6) of 43 sampled residents. This deficient practice...
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Based on interviews and record review, the facility failed to ensure the medical provider was notified of a resident's severe weight loss, for one (#6) of 43 sampled residents. This deficient practice did not allow the physician the opportunity to plan or implement weight loss interventions. Findings include: During an interview on 7/15/25 at 8:32 a.m., resident #6 stated she had lost 26 pounds in the last month or two and was not sure why her appetite had declined.Review of resident #6's electronic health record showed resident #6 weighed 308 pounds on 1/6/25 and 248 pounds on 7/16/25, which was a 19.51% loss over the past six months; and on 6/9/25 she [resident #6] weighed 276 pounds, which was a 10.14% loss over the past month.During an interview on 7/16/25 at 9:16 a.m., staff members Z and AA stated resident #6 was independent with feeding herself, and they were not sure why resident #6's appetite was declining. Staff members Z and AA stated resident #6's son and daughter-in-law were aware of the weight loss. During an interview on 7/16/25 at 1:52 p.m., staff members AA and BB stated they were not aware resident #6 had lost 60 pounds over the last six months, or 26 pounds in the last month. During an interview on 7/16/25 at 3:08 p.m., staff member D stated resident #6 was admitted to the Nutrition at Risk Committee in May of 2025. Staff member D stated physicians were to be notified of significant weight losses when residents were admitted or discharged from the Nutrition at Risk Committee. Review of the electronic medical record for resident #6 showed a Nutrition at Risk Committee note, dated 6/24/25 at 2:29 p.m., reflected: .Significant weight loss in 6 months . Resident Care Manager to notify provider of weight loss .During an interview on 7/17/25 at 7:55 a.m., staff member F stated she did not notify resident #6's physician of the weight loss, I dropped the ball, I should have, it was my fault.During an interview on 7/17/25 at 8:53 a.m., staff member A stated the physician for resident #6 should have been notified of resident #6's significant weight loss in order to be involved with her care. Review of a facility policy titled, Weight/Nutrition at Risk, BH320, last revised 1/2023, showed: .All significant changes in weight (5% in 30 days; 10% in 180 days), .will be reported to the patient's/resident's provider .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
Could have caused harm · This affected 1 resident
Based on observations, interviews, and record review, the facility failed to provide residents access to grievance forms and the opportunity to file grievances anonymously for 1 (#8) of 43 sampled res...
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Based on observations, interviews, and record review, the facility failed to provide residents access to grievance forms and the opportunity to file grievances anonymously for 1 (#8) of 43 sampled residents. Findings include: During an interview on 7/15/25 at 1:17 p.m., resident #8 stated the nurse practitioner told him he was dying, and his kidney function was down 63%. Resident #8 stated he was rushed to the hospital, and the hospitalist stated he was not dying, and his kidney function numbers were not that bad, and gave him a bolus of IV fluids. Resident #8 stated he was angry that the nurse practitioner put him and his wife through that trauma. Resident #8 stated he tried to figure out answers from the staff and was not able to get any answers. Resident #8 stated he was not aware of any grievance forms and had not seen grievance forms. Resident #8 stated he was very vocal about his concerns about the nurse practitioner scaring him and his wife with false information, but his wife would most likely want to file a grievance anonymously if she had the opportunity. Resident #8 requested a couple of forms to complete from the surveyor to file a grievance related to his concerns about the nurse practitioner scaring him and his wife with false information, and his concerns with the quality and temperature of food.During an observation on 7/15/25 at 1:30 p.m., no grievance boxes or forms were observed on the walls or in common areas of the unit. During an observation and interview on 7/15/25 at 1:33 p.m., staff members U, E, and Y looked through the nursing station on the unit and the file cupboards but were not able to locate any grievance forms. Staff member E called staff member B, who stated she would bring a form to the unit. Staff member E stated the forms were not kept on the units in the years she had worked for the facility.During an interview on 7/15/25 at 1:37 p.m., staff member H stated he had a form on his computer but was unsure of the process for handling it and would need to call staff member B for the process. Staff member H stated the forms were not readily available for residents to use anonymously.During an interview on 7/15/25 at 1:45 p.m., with staff member B and J, staff member B was unable to find grievance forms on the 400-hall but did locate forms in the back office on the 600-hall. Staff member J stated he did not know where to find the forms and would need to call a manager on duty for assistance and did not know how residents would complete a grievance anonymously.During an interview on 7/15/25 at 2:01 p.m., staff member A stated the residents did not have access to grievance forms on the units to complete them anonymously. Staff member A stated that the residents can ask staff for a form. Staff member A stated the form staff member B found in the 600 hall was not the correct form. Staff member A stated the facility preferred to address concerns in the moment rather than handling forms filed anonymously.A review of the facility's policy, Patient Complaints and Grievances, revised 7/2025, reflected:- 1. At the time of admission or check-in, patient registration staff will provide patients and patient representatives with the Patient Rights & Responsibilities, which will describe how to submit Complaints and Grievances as well as the investigation and resolution process. There was no information or instructions for residents to file a grievance anonymously. A review of the facility provided, Facility Rights and Responsibilities, dated 4/15/25, reflected:- . (20) GRIEVANCES. To voice grievances to the facility or the resident council about care or treatment you or other residents receive, without discrimination or reprisal. The facility shall establish written procedures for receiving, promptly handling, and in- informing you or the resident council of the outcome of any grievance presented, including those with respect to the behavior of other residents. You also have the right to ask a state agency or a resident advocate for assistance in resolving grievances, free from restraint, interference, or reprisal. There was no information or instructions for residents to file a grievance anonymously.A review of the facility provided list of grievances, with no date, did not reflect any grievances filed for resident #8, including after he returned from the hospital and voiced his concerns.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0604
(Tag F0604)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to keep a resident free from a physical restraint for 1 (#60) of 1 sampled resident. This deficient practice caused the resident...
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Based on observation, interview, and record review, the facility failed to keep a resident free from a physical restraint for 1 (#60) of 1 sampled resident. This deficient practice caused the resident to be unable to get out of a Broda chair independently, and caused the resident to be agitated and yell to get out of the chair. Findings include:During an observation on 7/16/25 at 8:42 a.m., resident #60 was sitting in a Broda chair. The back of the chair was reclined at about a 45-degree angle, and the footrest was in the up position. The resident's feet were unable to reach the floor. Resident #60 was sitting parallel to a table in the dining room. Resident #60 was yelling that he wanted out of the chair, and he was trying to climb over the arm of the chair.During an observation on 7/16/25 at 8:52 a.m., resident #60 continued to be in the Broda chair, sitting parallel to a table in the dining room. Resident #60 was attempting to get out of the Broda chair, but he was not able to. The Broda chair was reclined at about a 45-degree angle, and the footrest was in the up position, so his feet were not able to reach the floor. Resident #60 became agitated, then he threw a blanket and three pillows onto the floor in the dining room. Resident #60 stated, Get me out of this chair, multiple times. Resident #60 tried to climb over the arm of the chair and slide off the end of the chair.During an interview on 7/16/25 at 9:12 a.m., staff member N stated, We put [Resident #60] in the Broda chair to prevent falls. From what I understand, he was falling out of his wheelchair all the time, so we started putting him in this one (Broda chair) so he couldn't fall. During an interview on 7/16/25 at 10:17 a.m., staff member S stated she frequently worked with resident #60, and the use of the Broda chair was either a directive of nursing or physical therapy. Staff member S stated that resident #60 had been using the Broda chair for about three months. During an observation on 7/16/25 at 12:55 p.m., resident #60 continued to sit in the dining room in the Broda chair. Resident #60 appeared anxious and agitated, stating, I want out of this chair, get me out of this, repeatedly. During an interview on 7/16/25 at 1:05 p.m., staff member LL stated that resident #60 was always upset when he was in the Broda chair, but he would fall out of his wheelchair.During an interview on 7/16/25 at 1:42 p.m., staff member N stated, [#60's name] is uncooperative and agitated today. Staff member N stated the (Broda) chair was most likely the cause of resident #60's agitation. Staff member N stated he was not sure of any alternative interventions implemented for the falls, before the use of the Broda chair, for resident #60.A review of resident #60's care plan, dated 3/1/25, with a revision date of 6/24/25, showed no alternate interventions for falls were attempted prior to the use of the Broda chair.A request for the restraint policy and procedure was made on 7/16/25.During an interview on 7/16/25 at 2:30 p.m., staff member A stated there was no policy or procedure for restraints because the facility was a restraint-free facility.During an interview on 7/17/25 at 7:50 a.m., staff member P stated she had not worked at the facility for very long. Staff member P stated if a resident needed a different type of chair or special equipment, physical therapy should do an assessment and give a recommendation on the equipment. Staff member P stated she did not believe an assessment had been completed on resident #60 for the use of the Broda chair and did not believe an assessment was done to assess the safety of resident #60 in the Broda chair.Review of resident #60's Physical Therapy Discharge Summary, dated 2/26/25, showed: Equipment issued: Recommend continued use of hospital bed, full body mechanical lift for transfers and standard manual w/c.Review of resident #60's Significant Change MDS, with an Assessment Reference Date of 6/25/25, showed a restraint was not coded.Review of #60's physician orders, dated 2/2025 to 7/17/25, showed no physician order for a restraint.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
Based on interview, and record review, the facility failed to complete a baseline care plan within 48 hours of admission, to include the minimum health information necessary to properly care for 1 (#8...
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Based on interview, and record review, the facility failed to complete a baseline care plan within 48 hours of admission, to include the minimum health information necessary to properly care for 1 (#87) of 6 residents sampled for baseline care plans. This deficient practice puts the resident at risk of not receiving necessary care and services. Findings include: During an interview on 7/16/25 at 10:40 a.m., staff member N stated he does not review the resident care plans, and he did not look at resident #87's baseline care plan.During an interview on 7/18/25 at 8:35 a.m., staff member E stated she helped oversee the care planning process and ensured staff are following the care plans. Staff member E stated baseline care plans are completed within 48 hours of admission. Staff member E stated that nursing staff were supposed to help initiate and update care plans.Review of resident #87's baseline care plan, dated 6/27/25 at 5:47 p.m., showed the baseline care plan was not filled out and did not identify any information pertinent to care for the resident. Baseline care plan information did not include resident #87's cognitive status, ADL status, bowel or bladder status, transfer status, respiratory status, specifically oxygen use, communication status, mobility device use, or type of diet. Review of Resident #87's diagnosis list showed a diagnosis of Lung Cancer, Pain and Diabetes Mellitus, Type II.Review of a facility policy titled Care Planning Process, BH125, with a revision date of 3/2025, showed: . The care plan must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being Care plans are initiated upon admission .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to update care plans as resident conditions and physician orders changed for 2 (#s 13 and 60) of 43 sampled residents. Findings include:1.Revi...
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Based on interview and record review, the facility failed to update care plans as resident conditions and physician orders changed for 2 (#s 13 and 60) of 43 sampled residents. Findings include:1.Review of a facility document provided to resident #60’s physician, dated 6/11/25, showed:
… “Resident #60 has poor appetite and intake he does drink his boost… Staff attempt 1 on 1 with meals and encourage intake…”
Review of resident #60’s care plan, with an initiation date of 6/11/25, showed severe weight loss as a focus area. The care plan was not updated to include one on one feeding provided by staff as needed or the use of nutritional supplements.
During an interview on 7/16/25 at 1:05 p.m., staff member LL stated, During an observation and interview on 7/16/25 at 1:05 p.m., staff member LL picked up resident #60’s meal tray and put it in a cart to be thrown away. Everything on the meal tray was still covered and untouched. Staff member LL stated, We don't make him (resident #60) eat, he is on comfort care.
During an interview on 7/16/25 at 3:10 p.m., staff member D stated, “Resident #60 is on comfort care, so we can’t make him eat. Staff member D stated resident #60 was being followed in the nutrition at risk meetings because of his weight loss. Staff member D stated patient #60 requires encouragement and one on one occasionally with meals, and staff are to be offering alternative meals if he does not eat.
During an interview on 7/18/25 at 8:35 a.m., staff member E stated she helped oversee the care planning process and ensured staff were following the care plans. Staff member E stated care plans were done on admission, quarterly, annually, and with any significant change. Staff member E stated it was her expectation that nurses on the floor also assist in revising resident care plans.
2. During an interview on 7/17/25 at 7:43 a.m., staff member G, stated resident care plans were updated in an ongoing matter as things developed. Adding something like a catheter, medications, or behaviors would indicate a care plan update.
Review of resident #13's physician orders, dated 7/9/25 - 7/11/25, showed the resident's catheter was removed for a voiding trial and there were orders to, bladder scan every four to six hours and straight cath for retention of greater than 500ml urine.
Review of resident #13's care plan, with an initiation date of 7/8/25, showed risk for infection due to indwelling catheter as a focus area. The care plan had not been updated to include the removal of the catheter or the two new orders of bladder scanning and as needed straight catheterization.
Review of a facility policy titled, “Care Planning Process, BH125,” with a revision date of 3/2025, showed:
… “2. Care plans are reviewed and updated after each MDS assessment, and as the resident’s needs and strengths change, and to update time frames, goals, approaches, and objectives.”
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to provide assistance with meals for a resident who required encouragement and one on one for eating for 1 (#60) of 5 sampled re...
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Based on observation, interview, and record review, the facility failed to provide assistance with meals for a resident who required encouragement and one on one for eating for 1 (#60) of 5 sampled residents for nutrition. This deficient practice increased the risk for the resident not receiving necessary care and services with meals. Findings include:During an observation on 7/15/25 at 8:15 a.m., resident #60 was lying in bed sleeping. Resident #60's breakfast tray was sitting on his bedside table, covered and untouched.During an observation on 7/16/25 at 8:42 a.m., resident #60 was sitting in a Broda chair parallel to the table, with his feet elevated and the back of the chair reclined. Resident #60's breakfast tray was sitting on the table. The tray had a cover over the plate of food, the milk and juice each had a cover over them, and the container of boost was unopened. Staff member N was the only staff member near the dining area. Resident #60 could not reach his tray of food.During an observation on 7/16/25 at 8:45 a.m., staff member R entered the dining area and picked up resident #60's meal tray. Staff member R did not offer any assistance to resident #60 or offer an alternative prior to taking the tray away.During an interview on 7/16/25 at 8:58 a.m., staff member S stated resident #60 was agitated and that was probably why he did not eat. Staff member S stated staff was to encourage resident #60 to eat or provide one on one assistance to resident #60.During an observation on 7/16/25 at 12:55 p.m., resident #60 was sitting in a Broda chair with the feet elevated and the back reclined. The Chair was parallel to the dining table. Staff member LL was sitting at the end of the dining table with two residents between resident #60 and staff member LL. Resident #60's meal tray was still covered, and he could not reach his fluids. Resident #60 stated, Hell yeah, I'm hungry. Staff member LL got up from the end of the table and sat next to resident #60. Staff member LL did not uncover the meal tray or attempt to encourage or assist resident #60 with his meal.During an observation and interview on 7/16/25 at 1:05 p.m., staff member LL picked up resident #60's meal tray and put it in a cart to be thrown away. Everything on the meal tray was still covered and untouched. Staff member LL stated, We don't make him (resident #60) eat, he is on comfort care.During an observation on 7/16/25 at 1:20 p.m., resident #60 was sitting in the dining area yelling, I'm hungry.During an interview on 7/16/25 at 1:30 p.m., staff member S stated resident #60 feeds himself, staff do not need to assist him, but there are times when he needed encouragement to eat. Staff member S stated breakfast comes to the unit about 7:15 a.m. and lunch arrives about 12:15 p.m.During an interview at 1:35 p.m., staff member N stated resident #60 feeds himself. Staff member N stated, Today he (the resident) is just agitated and uncooperative, so he's not eating.During an interview on 7/16/25 at 3:10 p.m., staff member D stated, Resident #60 is on comfort care, so we can't make him eat. Staff member D stated resident #60 was being followed in the nutrition at risk meetings because of his weight loss. Staff member D stated patient #60 requires encouragement and one on one occasionally with meals, and staff are to be offering alternative meals if he does not eat.During an observation on 7/17/25 at 8:12 a.m., resident #60 was lying in bed asleep. Resident #60's meal tray was on his bedside table.Review of resident #60's care plan showed: Focus: Severe weight loss-date initiated 6/11/25,Goal: Resident to consume greater than 50% of each meal-initiation date 6/11/25.Interventions: Encourage to eat 50 percent or more of meals.-If intake 50 percent or less, offer substitute or supplement.Review of a facility document titled, Weight/Nutrition at Risk, BH320, with an effective date of 3/2025, showed:. 4. To ensure all residents are having their nutritional needs met.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure an Unstageable pressure injury received care and services to prevent worsening of a pressure injury after admission fo...
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Based on observation, interview, and record review, the facility failed to ensure an Unstageable pressure injury received care and services to prevent worsening of a pressure injury after admission for 1 (#5) of 3 sampled residents for pressure ulcers. Resident #5 was admitted with an Unstageable pressure injury to his right heel. There was a lack of information to determine if the wound was worsening. Findings include:During an observation and interview, on 7/16/25 at 11:11 a.m., staff member I performed a dressing change on resident #5's right heel. Staff member I donned clean gloves and removed the soiled dressing. The dressing was saturated with yellow exudate and yellow slough was covering the wound. The wound was not cleansed prior to putting the clean dressing on. Staff member I stated wound care orders were usually on the TAR, but she did not see any orders for wound cleansing. The wound was covered with Aquacel and wrapped in Kerlix.During an interview on 7/17/25 at 8:48 a.m., staff member E stated resident #5 was supposed to have boots on for offloading. Staff member E stated, for wound prevention, the resident had an air mattress. Staff member E stated a foot cradle was tried, but the resident did not like it. Staff member E stated the resident was also supposed to be turned and repositioned. Resident #5 was identified to have nutrition at risk. Staff member E stated staff member D had recommended Juven for the resident for wound healing. Resident #5 was to receive every other day dressing changes. During an interview on 7/17/25 at 9:30 a.m., staff member MM stated resident #5 was to use a boot (pressure relieving) on his heel, be turned and repositioned, his bed had an air mattress, and staff were to float his heels while in bed. Staff member MM stated the resident was to leave the boot on all day. Staff member MM stated resident #5 was to be up to the dining room for meals.During an interview on 7/17/25 at 9:58 a.m., staff member B stated there was a policy for wound care, and upon admission staff were to assess and evaluate any wounds the resident had. The interventions were to be care planned and staff were to follow physician orders for wound care. Staff member B stated the staff had pressure ulcer training recently. Staff member B stated the resident came in with the wound to his right heel.Review of resident #5's wound consult notes showed the wound was Unstageable on 6/23/25, and it was a Stage II pressure injury on 7/7/25. The note on 6/23/25 showed the wound was Unstageable due to the inability to debride the wound due to pain. No additional wound care notes were provided during the survey.Review of resident #5's Orthopedic Progress Notes, showed the heel wound was described as having partial thickness, and the resident had a boot for offloading.Review of resident #5's Skilled Nursing visits showed the heel wound was Unstageable on 6/14/25 and 6/20/25. On 7/3/25 the heel wound was to be offloaded continuously to ensure wound healing and wound care had been consulted on 6/23/25. On 7/8/25, the heel wound was not mentioned. An addendum to a note, dated 6/30/25 for the encounter note dated 6/25/25, showed the heel wound was being managed by the wound team and offloading with daily dressing changes.Review of a Skin and Wound Evaluation, dated 7/10/25, showed the heel wound was an Ustageable pressure deep tissue injury present on admission which measured 2.9 cm x 2.2 cm. The wound had light seropurulent drainage with a faint odor. The wound was documented as slow to heal. This was the only Skin and Wound Evaluation provided by the facility. Review of the facility policy, titled Skin and Wound Care, showed any skin breakdown on admission was to be reported to the provider, the family member and/or the Representative and the Resident Care Manager immediately. All identified pressure or open wounds were assessed, photographed, and measured weekly by the licensed nurse in order to identify progress towards healing, and any new treatments needed.The heel wound documentation provided by the facility did not show measurements, or weekly assessments, and did not show complete wound care including cleansing the wound.Review of resident #5's Care Plan showed there were not any new interventions or changes for wound management since 6/21/25. Interventions included evaluation, monitoring, and measuring the wound at regular intervals, but time frames were not specified.Review of the facility policy titled, Skin, Wound and Pressure Injury Prevention showed: . skin, wound and pressure injuries will be treated using the skin, wound and pressure injury care guideline . Comprehensive wound and pressure injury documentation will be completed weekly until discharge, unless otherwise indicated per provider's direction. Photograph wound or pressure injury on admission . Photographs will be completed once weekly until discharge.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure a resident was provided tube feeding without complications to maintain his weight for 1 (#69) of 2 sampled residents f...
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Based on observation, interview, and record review, the facility failed to ensure a resident was provided tube feeding without complications to maintain his weight for 1 (#69) of 2 sampled residents for tube feeding. Findings include:During an observation on 7/15/25 at 8:25 a.m., resident #69's doorway had an enhanced barrier precaution sign posted. Resident #69 was in his recliner with his feet up and had his call light on. A tube feeding was hanging on a pole behind a bedside table with a suction machine on top of it. An unidentified CNA entered the room and resident #69 stated his tube feeding was leaking again. The unidentified CNA left to get staff member NN. Both the CNA and staff member NN entered the room. Neither staff member put on PPE other than gloves. The unidentified CNA cleaned up the leaked tube feeding and dumped the suction container into the sink and placed the container back on the bedside table. Staff member NN cleaned the tube feeding off resident #69's abdomen. She then adjusted the lock on the tube feeding where it was attached to the resident.During an interview on 7/15/25 at 8:44 a.m., staff member NN stated resident #69's tube feeding had just started, and it was locked so the pressure from the machine running had caused it to open and leak. Staff member NN stated she went into the resident's room, cleaned up the tube feeding that had leaked, then she unlocked the clamp so the tube feeding would administer.During an interview on 7/16/25 at 3:15 p.m., staff member D stated she had realized there was no more Isosource tube feeding bags when she saw the empty shelf in the kitchen. Staff member D stated she did not have a role in ordering supplies and could not write orders for diet or tube feeding supplements. Staff member D stated she informed the units they would need to temporarily use a different tube feeding formula and wrote progress notes for the substitution. Staff member D stated the alternate formula had been used for all residents receiving tube feeding for the last two days. She stated they were out of Isosource, and the current formula being used did not have the same caloric nutrients as the Isosource.During an interview on 7/17/25 at 9:17 a.m., staff member HH stated, he ordered to a par level of six for the Isosource 1.5 tube feeding formulas, but he had no way of knowing how many were needed in a day and it varied. Staff member HH stated he had Isosource ordered but the construction in front of the distributor blocked their route and delayed the shipment. He stated he doubled the order and was told it would be delivered that afternoon.During an interview on 7/17/25 at 10:50 a.m., staff member F stated the unit was told to substitute the Fibersource and it was supposed to be only substituted for one tube feed for the resident. She stated the Isosource was again delayed, so they had been using the Fibersource until the Isosource was delivered. Staff member F stated there was no new physician order for the change in the tube feeding. Staff member F stated staff member D came to the unit to inform the nursing staff of the delay in the Isosource delivery. She stated the kitchen staff had delivered the alternate tube feeding formula.Review of resident #69's physician orders, for his tube feeding, showed he was to be given Isosource 1.5. The TAR showed Isosource had been given when it was not available on 7/15/25 and 7/16/25. There were no new orders for the temporary change of the tube feeding formula from Isosource to Fibersource. The resident's orders showed the physician was not notified of the change in tube feeding formula. There was an order added for daily weights for two days entered on 7/15/25. As of 7/17/25, no weights had been documented. Review of resident #69's progress notes showed:- Nutrition Note on 7/14/25, No nutrition concerns at this time. Tolerating enteral nutrition at goal rate. Followed by NAR program. Diet Isosource 1.5. No significant weight loss in 1 or 3 months. No 6-month weight history.- Nutrition Note on 7/15/25, Kitchen is out of Isosource 1.5. Provide Fibersource HN at ordered rate until Isosource 1.5 is back in stock. RD to continue to monitor.Review of resident #69's weight on 3/10/25 showed 160 lbs. On 3/31/25 his weight was 149.5 lbs. There was a 6.65% weight loss between 3/10/25 and 3/31/25. A review of the weights for July 2025 showed no weights were documented in the EHR for the resident. Review of the facility policy, Adult Confirmation and Management of Feeding Tubes/Nasogastric Tubes, AGN470, last revised 5/25/25, showed, Patient weights should be obtained Monday, Wednesday, and Friday.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility licensed nursing staff failed to ensure a physician's order was in place for a resident's oxygen use, for 1 (#87) of 3 sampled resident...
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Based on observation, interview, and record review, the facility licensed nursing staff failed to ensure a physician's order was in place for a resident's oxygen use, for 1 (#87) of 3 sampled residents for oxygen use. Findings include:During an observation on 7/14/25 at 4:15 p.m., resident #87 was lying in bed with oxygen on via nasal canula, and the oxygen concentrator was set to 1.5 liters.During an interview on 7/15/25 at 8:08 a.m., resident #87 stated he had a diagnosis of lung cancer that had spread, and he was terminal. Resident #87 stated he used oxygen all the time.During an interview on 7/18/25 at 8:35 a.m., staff member E stated that nursing staff were responsible for getting orders from the physician. Staff member E stated it was her expectation for nursing staff to notify the physician of any changes and get the physician's orders needed, and if oxygen is needed, the nursing staff should let the physician know right away and get the corresponding order.Review of resident #87's physician's orders, dated 6/27/25-7/14/25 showed no orders for oxygen use.Review of a facility document titled Adult Oxygen Therapy at [Facility Name], BH243, with a revision date of 6/2023, showed:. Initiation of Oxygen1. Oxygen therapy will only be initiated by provider order.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure staff adhered to standards of practice for infection control by not using proper hand hygiene and glove changes during...
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Based on observation, interview, and record review, the facility failed to ensure staff adhered to standards of practice for infection control by not using proper hand hygiene and glove changes during wound care for 2 (#s 5 and 60), and failed to use proper infection control practices for 2 (#s 5 and 69) of 13 sampled residents for infection control by not adhering to practices for Enhanced Barrier Precautions by not wearing a gown during wound care, suctioning, and tube feeding. This deficient practice had increased the risk of the spread of infection for all residents in the facility. Findings include:
1. During an observation and interview on 7/16/25 at 11:11 a.m., staff member I performed a dressing change on resident #5's right heel. Staff member I donned clean gloves and removed the soiled dressing. The dressing was saturated with yellow exudate, and slough was covering the wound. Staff member I did not change gloves or sanitize hands between removing the dressing and applying the clean dressing. The wound was not cleansed prior to putting the clean dressing on. Staff member I stated wound care orders were usually on the TAR, but she did not see any orders for wound cleansing. The wound was covered with Aquacel and wrapped in Kerlix. Staff member I did not remove her gloves before departing the resident's room. The resident was on EBP (Enhanced Barrier Precautions) which required gloves and gown for high contact ADLs and catheter cleaning. Staff member I did not wear a gown during the procedure.
During an interview on 7/17/25 at 9:58 a.m., staff member B stated there was a policy for wound care and the staff were expected to follow wound orders. The wound was assessed upon admission, and the provider was contacted for orders for wound care. Staff were to follow physician orders for wound care, including cleansing and proper infection control practices. Staff member B stated the staff were to follow infection control policies for wound care. Staff member B stated the facility had recently completed pressure ulcer training including training on infection control practices.
Review of the facility policy titled, “Hand Hygiene,” showed: . “All employees must achieve full compliance with the hand hygiene standards outlined in this policy and procedure…
when to perform hand hygiene . Immediately before each episode of direct patient contact/care, including clean/aseptic procedures .
immediately after each episode of direct patient contact/care .
immediately after the removal of gloves, including between the exchange of dirty to clean gloves .
before and after handling/administering medicines .
after removing personal protective equipment .
standard aseptic non touch technique such as wound care .
2. During an observation on 7/15/25 at 8:25 a.m., resident #69's doorway had an enhanced barrier precaution sign posted. Resident #69 was in his recliner with his feet up and had his call light on. A tube feeding was hanging on a pole behind a bedside table with a suction machine on top of it. An unidentified CNA entered the room and resident #69 stated his tube feeding was leaking again. The unidentified CNA left to get staff member NN. Both the unidentified CNA and staff member NN entered the room. Neither staff member put on PPE other than gloves while the unidentified CNA cleaned up the leaked tube feeding and dumped the suction container in the sink and placed the suction container back on the bedside table. Staff member NN cleaned up the tube feeding that was on the resident’s abdomen. She then adjusted the lock on the tube feeding where it was attached to the resident.
During an observation on 7/16/25 at 11:14 a.m., staff member OO entered resident #69’s room, donned gloves and connected the resident’s tube feeding and took the end of the suction off due to it falling on the ground. Staff member OO did not don a gown.
During an interview on 7/17/25 at 10:43 a.m., staff member F stated when providing cares for suction or tube feeding staff were expected to wear gowns and other PPE. The suction should be emptied in the toilet and rinsed out before replacing it back on the device.
3. During an observation on 7/15/25 at 10:45 a.m., staff member Q started wound care on resident #60. Resident #60 had wounds to his bilateral lower extremities. Staff member Q donned a gown and gloves prior to entering resident #60’s room. After staff member Q donned the person protective equipment, she knocked on the door to resident #60’s room and opened the door. Staff member Q did not change her gloves after touching the door and entering the room. Staff member Q opened the xeroform package and placed the xeroform on to the wound located on the right lower extremity. Staff member Q opened two ABD packages and placed the ABDs over the Xeroform. Staff member Q removed her left glove and replaced it with a new glove. No hand hygiene was performed prior to replacing the left glove. Staff member Q wrapped the area in Kerlix (gauze). Staff member Q opened another Xeroform package and placed the Xeroform to the wound located on the left leg. Staff member Q doffed her glove and gown and left the room. No hand hygiene was completed prior to or after exiting the room. Staff member Q entered the supply area and retrieved more supplies for resident #60. Staff member Q walked over to the medication cart, placed the supplies on top of the medication cart and went back into the supply area. Staff member Q exited the supply closet went back to the medication cart touched the top and the sides of the medication cart and picked up the supplies. Staff member Q walked back to resident #60’s room donned a new gown and gloves and entered the room. No hand hygiene was completed prior to donning the gown and gloves. Staff member Q opened the two ABD packages and placed ABD pads to the wound located on the resident’s left lower extremity. Staff member Q opened the Kerlix (gauze) and placed it on the bed with resident #60, while she moved a pillow, and moved a blanket and a stuffed animal away from resident #60. No glove change or hand hygiene was completed after contaminating the glove. A new roll of Kerlix was not retrieved after contaminating the Kerlix on the bed. Staff member Q wrapped the wound in the Kerlix. Staff member Q doffed her gown and gloves in the trash, tied the trash bag and left the room. Staff member Q walked through the dining area with trash, entered the soiled utility room and disposed of the trash. No gloves were donned while handling the trash, and no hand hygiene was performed after disposing of the trash. Staff member Q walked over to the medication cart and grabbed a medication card.
During an interview on 7/15/25 at 11:25 a.m., staff member Q stated hand hygiene was to be performed prior to entering and exiting resident’s rooms, before and after resident care, after doffing any personal protective equipment, and when your hands become soiled. Staff member Q stated, “I should have done more hand hygiene during wound care and after I was finished but I just didn’t think about it.” Staff member Q stated she had been educated on infection control, hand hygiene, and enhanced barrier precautions.
During an interview on 7/17/25 at 9:00 a.m., staff member K stated she provided the staff with infection prevention and hand hygiene education. Staff member K stated infection prevention education, including hand hygiene was done on hire and yearly. Staff member K stated if there was a concern or she had witnessed a concern she would provide in the moment education with staff, and if there continued to be concerns with a certain area it would be escalated to the managers. Staff member K stated the expectation for infection prevention and hand hygiene was for staff to follow the policies and to make sure they were using PPE appropriately and performing appropriate hand hygiene.
A review of a facility document titled, “Hand Hygiene, ICP104,” with a revision date of 2/2025, showed:
… “Policy
1. [Facility Name] recognizes hand washing as the most important health procedure any individual can perform to prevent the spread of microbes.
2. All employees must achieve full compliance with the hand hygiene standards…,
Procedure:
1. Patients are put at risk for developing an HAI when the health care workers caring for them have contaminated hands.
… Perform hand hygiene:
A. Immediately before each episode of direct patient contact/care, including clean/aseptic procedures,
B. Immediately after each episode of direct patient contact/care,
D. After handling contaminated laundry and waste,
F. Before and after leaving isolation rooms/bays.”
Review of a facility document titled, “Enhanced Barrier Precautions Policy ICP326,” with a revision date of 5/2024, showed:
… “Personal Protective Equipment (PPE)
A. Gloves and gown are doffed into a garbage within the resident room after each resident encounter and hand hygiene is performed.
C. Hand hygiene is performed between each resident after doffing.”[sic]
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure residents received, or had the opportunity to receive, the pneumococcal vaccine series for 2 (#s 1 and 87) of 5 sampled residents fo...
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Based on interview and record review, the facility failed to ensure residents received, or had the opportunity to receive, the pneumococcal vaccine series for 2 (#s 1 and 87) of 5 sampled residents for vaccinations. Findings include:During an interview on 7/17/25 at 9:00 a.m., staff member K stated immunization information is collected on admission. Staff member K stated she collected the immunization requests or declinations weekly, and if a resident would like a vaccine, she would order it and provide it to the resident. Staff member K stated she was not sure why vaccinations were missed. Staff member K stated if a resident had a prior pneumococcal vaccine they were considered immune. Staff member K could not verbalize the current recommendations for pneumococcal vaccines in adults.1. Review of resident #1's vaccine consent form dated, 10/22/24, showed resident #1's representative consented to all immunizations to include pneumococcal.Review of resident #1s immunization documentation showed he had received pneumococcal 23 vaccine on 7/28/2016.The CDC (Centers for Disease Control) recommends the pneumococcal 20 or pneumococcal 21 for people who only received the pneumococcal 23 vaccine at any age, and it has been greater than one year since administration.(www.cdc.gov/pneumococcal/downloads/vaccine-timing-adults-jobaid.pdf)2. Review of resident #87's electronic medical record from 6/27/25 to 7/17/25, showed no vaccination history or vaccination consent.During an interview at 10:44 a.m., resident #87 stated he had not been asked about vaccinations upon admission.A request for resident #87's vaccination consent was requested on 7/17/25 at 7:55 a.m., and was not received prior to the end of the survey.The CDC (Centers for Disease Control) recommends the pneumococcal 20 or pneumococcal 21for people who have never had any pneumococcal vaccines.(www.cdc.gov/pneumococcal/downloads/vaccine-timing-adults-jobaid.pdf)Review of a facility document titled, Pneumococcal for Long Term Care Units, IPC216, with a revision date of 9/2024, showed: Policy: The facility will follow CDC recommendations on immunization for pneumococcal disease for those 65 years and older, or for those 19-64 with certain underlying medical conditions or risk factors. [sic]
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0554
(Tag F0554)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to obtain evaluations and provider orders for residents to self-administer medications for 4 (#s 28, 40, 90, and 93) of 11 resid...
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Based on observation, interview, and record review, the facility failed to obtain evaluations and provider orders for residents to self-administer medications for 4 (#s 28, 40, 90, and 93) of 11 residents sampled for self administration capabilities. Findings include:1. During an observation and interview on 7/16/25 at 12:55 p.m., resident #90 was lying in bed with her nebulizer running, and the nebulizer mouthpiece was under her blanket. Resident #90 stated she tried to hold the nebulizer up to her mouth but was busy on her cell phone looking for something and became tired. Resident #90 appeared to be short of breath and was coughing throughout the interview.
During an interview on 7/16/25 at 12:56 p.m., staff member L stated he usually set up the nebulizer, and resident #90 completed the nebulizer treatment on her own. Staff member L stated the nurses were responsible for filling out the self-administration of medication evaluation and requesting an order from the physician. Staff member L reviewed resident #90's paper chart and EHR, stating he could not find a self-administration evaluation or an order for resident #90 to self-administer medications.
A review of resident #90's EHR reflected that resident #90 had an order for Ipratropium-Albuterol solution 3 ML, inhale orally, four times daily.
A review of resident #90's paper chart reflected that resident #90 was seen by the physician on 7/16/25 at 4:15 p.m., and physician orders were received for Mucinex, for the resident's cough, and Augmentin and Doxycycline, for pneumonia.
2. During an observation and interview on 7/16/25 at 8:42 a.m., resident #28 was sitting in his recliner watching television. A cup of pills was on his bedside table next to the recliner. Resident #28 stated, They leave them (the pills), and I take them at some point.
During an observation and interview on 7/17/25 at 8:50 a.m., resident #28 was sitting in his recliner watching television. A cup of pills was on the bedside table next to the recliner. Resident # 28 stated, Oh, I should probably take my pills, huh?
During an interview on 7/17/25 at 10:27 a.m., staff member L went through the paper charts for resident #28 and stated that resident #28 did not have an assessment or physician order for the self-administration of medications. Staff member L stated resident #28 took a half hour to take his medications because of a swallowing issue, so he leaves the pills with the resident so he can take them at his own pace.
A review of resident #28's EHR reflected resident #28 had an order for Ipratropium-Albuterol solution 3 ML, inhale orally, four times daily.
3. During an observation and interview on 7/15/25 at 10:12 a.m., resident #40 had a full cup of pills on her table. There was no staff supervision at the time. Resident #40 set the medications off to the side and stated she would take them later.
Review of resident #40's medication administration record, dated 7/15/25, showed that for the a.m. medications she received: Famotidine for acid reflux, levothyroxine for hypothyroidism, acetaminophen for pain, and Eliquis, a blood-thinning medication, for atrial fibrillation.
Review of resident #40's Annual MDS, with an ARD of 5/19/25, showed she had a BIMS of 7; severe cognitive impairment.
Review of resident #40's medical record failed to show she was assessed to safely administer her medications.
4. During an observation and interview on 7/15/25 at 3:22 p.m., resident #93 brought a plastic bag with assorted pills to the nurse. Staff member J stated they had no idea where the resident got them from, and they were not in facility packaging.
During an interview on 7/16/25 at 10:37 a.m., staff member I stated that a resident had to have an order for self-administering medications or the nurse would have to remain with and watch the resident take the medications.
During an interview on 7/16/25 at 10:42 a.m., staff member J stated “99% of the time we watch the residents take their meds, if I know a resident well, and there are no cognitive issues and no controlled meds, I will sometimes leave the meds with them and keep checking back on them to make sure they took them and didn’t drop any.”
During an interview on 7/16/25 at 1:53 p.m., staff member K stated, “The nurses do not leave medications at the bedside. The resident would have to have a medication self-administration assessment and a provider order, for the nurses not to observe the resident taking the meds.”
A review of a facility provided list, titled, “Self-Administration,” listed six residents, who were the only residents approved by the facility to self administer medications. Resident #’s 28, 40, 90, and 93 were not on the list.
A review of #28, 40, 90, and 93's provider orders, located in the EHRs, failed to show a provider order allowing the resident to self-administer medications.
A review of a facility document titled, “Interdisciplinary Team Evaluation of Resident Self-Administration of Bedside Medications,” undated, showed:
“… Interdisciplinary Team Evaluation:
The interdisciplinary team has evaluated and assessed [blank]’s cognitive, physical and visual ability to carry out the responsibility of self-administering drugs. (Check one)
( ) Yes, [blank] is cognitively, physically and visually able to self-administer all of her/his dispensed medications in a medication cup left at her/his bedside
( ) Yes, [blank] is cognitively, physically and visually able to self-administer certain medications. …”
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to implement care planned assessments for seatbelt use for 1 (#1); failed to include pertinent resident care items including car...
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Based on observation, interview, and record review, the facility failed to implement care planned assessments for seatbelt use for 1 (#1); failed to include pertinent resident care items including cardiac monitoring and CPAP settings into a comprehensive care plan for 2 (#s 12 & 19); failed to include focus, goals, or interventions on the comprehensive care plan for oxygen use and nutritional supplement use for 1 (#87); and failed to include ADL's and mobility on a comprehensive care plan for 2 (#s 30 and 87) of 43 sampled residents. Findings include:1. During an interview on 7/17/25 at 7:43 a.m. staff member G stated resident #12 had been moved to the pod in May, and she was currently working on her most recent MDS assessment to trigger care plan updates. Staff member G stated care plan updates were also ongoing as resident concerns developed, and this would trigger an update for additional devices or medications.
Review of resident #12's hospital H&P, dated 2/20/25, showed the resident had been admitted for syncope and collapse, which resulted in the resident having a cardiac pacemaker placed.
Review of resident #12's nursing progress notes, dated 7/7/25, showed, The cardiac monitoring company called this morning to say [Resident #12's] pacemaker monitor was offline … The facility had further communications to replace the lost monitor.
Review of resident #12's comprehensive care plan, with an initiation date of 1/31/25, failed to show the resident was on any cardiac monitoring.
2. During an interview on 7/16/25 at 2:12 p.m., resident #19 stated she had always been an anxious person, but was having increased anxiety at night, which worsened her respiratory status. Resident #19 stated she had a paid caregiver who would stay with her at night when she lived at home, and she continued to pay this person to stay with her at night, from 11:00 p.m. to 6:00 a.m., in the facility as well. Resident #19 stated she had a bipap mask to wear when she slept, but it made her very claustrophobic, and she was reluctant to wear it even though she understood it would help when her breathing was difficult.
Review of resident #19's physician orders, dated 7/2/25, showed, BiPAP as HS and prn 3L O2 bleed in Trial of nasal bipap over mouth mask. [sic]
Review of resident #19's care plan, with an initiation date of 5/8/25, failed to show any documentation of the resident's nighttime sitter. The focus area of CPAP/BiPAP therapy did not have any interventions listed.
3. During an observation on 7/14/25 at 4:15 p.m., resident #87 was lying in bed with oxygen on, and the oxygen concentrator was set to 1.5 liters. There were three full, unopened containers of sugar-free boost, sitting next to his television. A walker was present in the room.
During an interview on 7/15/25 at 8:08 a.m., resident #87 stated he had a diagnosis of lung cancer that had spread, and he was terminal. Resident #87 stated he used oxygen all the time. Resident #87 stated he has had a decrease in his appetite, but the facility was providing him with boost at mealtimes. Resident #87 stated he does not always drink them.
Review of resident #87’s physician’s orders, dated 6/27/25 -7 /14/25, showed no physician order for the resident's oxygen use or the nutritional supplements provided at meals.
Review of resident #87’s comprehensive care plan, with an initiation date of 7/9/25, showed no focus, goals, or interventions for oxygen use or nutritional supplement use.
During an observation and interview on 7/15/25 at 10:15 a.m., resident #30 was sitting in a wheelchair at a table in the dining room, reading a book. Resident #30 stated he was able to move his wheelchair on his own by using his feet.
During an interview on 7/15/25 at 2:41 p.m., NF3 stated resident #30 had memory problems and required assistance with his ADLs and mobility.
During an observation on 7/16/25 at 12:40 p.m., resident #30 was in his wheelchair and was propelling himself, using his feet, back to his room.
Review of resident #30’s comprehensive care plan showed no focus, goals, or interventions for ADL’s or his mobility.
During an interview on 7/16/25 at 11:04 a.m., staff member S stated that residents #30 and #87 required assistance with ADLs and mobility. Staff member S stated she had a paper, which included information that showed her what each resident needed assistance with. Staff member S stated she did not look at the care plan, just the paper she had, which was basically a care plan.
During an interview on 7/18/25 at 8:35 a.m., staff member E stated she helped oversee the care planning process and ensured staff were following the care plans. Staff member E stated care plans were done on admission, quarterly, annually, and with any significant change.
Review of resident #87’s comprehensive care plan showed:
“Focus-The resident has an ADL self-care performance deficit r/t
Date initiated 7/14/25.
Goal-Resident will improve current level of function in (SPECIFY ADLs) through the review date. Resident will be able to: (SPECIFY).
Interventions-Praise all efforts at self care.” [sic]
Review of a facility CNA document showed:
“Resident #30- Bed: Ax2, Trans: Ax2, Gait Ax1 / WC.
Resident #87-Bed: Ax1, Trans: Ax1 FWW, Gait: Ax1 FWW.”
4. During an observation on 7/16/25 at 10:13 a.m., resident #1 was in his wheelchair in the 100-hall, and there was a seatbelt attached to the chair.
During an interview on 7/16/25 at 10:40 a.m., staff member N stated the nursing staff had become normalized” to resident #1 looking like he was going to fall out of his chair, due to his sliding down.
During an interview on 7/17/25 at 8:30 a.m., with staff members A and H, staff member A stated physician orders for the seatbelt use were obtained one time. Staff member H stated that physician orders were completed when a device was initially implemented, and no further orders were needed after. Staff member A stated the facility did not have a policy specific to seatbelt use.
During an interview on 7/17/25 at 10:16 a.m., staff member E stated when the facility changed to Point Click Care (electronic health record system), there was no template for the assessment for seatbelt use in residents, and this was why the quarterly assessments had not been done for resident #1 since October 2024.
Review of resident #1’s care plan, reviewed on 5/25/25, showed:
- “Obtain physician’s order to approve use of seat belt (ordered 12/2/23),”
“Assess quarterly that [resident #1] continues to be able to unbuckle as he/she wishes and that the safety belt is still functioning in helping with positioning needs in wheelchair.”
Review of a facility policy titled, “Care Planning Process, BH125,” with a revision date of 3/2025, showed:
… “The care plan must describe the services that are to be furnished to attain or maintain the resident’s highest practicable physical, mental and psychosocial well-being.
… 4. Care plans are individualized to address the resident’s problems, needs, severity of condition, impairment, disability, or disease. The care plan addresses needs and care priorities…” [sic]
A review of the facility’s policy, Care Planning Process, last revised 3/2025, showed, “… The interdisciplinary team collaborates throughout the provision of care to implement interventions that help achieve optimal outcomes and to communicate and coordinate the support of the resident needs and care goals.”
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to provide food at an appetizing temperature for 1 (#47) of 6 sampled residents for nutrition; and failed to ensure kitchen staf...
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Based on observation, interview, and record review, the facility failed to provide food at an appetizing temperature for 1 (#47) of 6 sampled residents for nutrition; and failed to ensure kitchen staff were wearing hair restraints, or wearing them properly, during food preparations. This deficient practice had the increased the risk of food borne illnesses for those who received meals in the facility. Findings include:1. During observations and interviews on 7/14/25 at 4:19 p.m., this surveyor was escorted into the kitchen by staff member CC through open double doors in the propped open position; no signage requiring hair coverings was noted; staff member CC walked approximately ten feet into the kitchen without a hair restraint, and was asked if she needed a hair net, her reply was, “Do I need a hair net?” Staff member DD was preparing dinner plates with her hair in a bun and a hat on; the hair by both of her ears had fallen out and was not restrained. Staff member EE was preparing dinner plates with a hair net on which did not restrain her hair from her forehead back approximately three inches.
During observation and interviews on 7/15/25 at 12:49 p.m., staff member FF was preparing raw bacon on a cookie sheet pan with no beard covering. Staff member HH stated he did not know the exact hair covering policy.
During an interview on 7/17/25 at 9:05 a.m., both staff members GG and JJ stated they were aware of staff not wearing appropriate hair restraints, and it was difficult to monitor because of the high turnover rate.
During an observation on 7/17/25 at 9:05 a.m., the front portion of staff member KK’s hair was not covered completely by her hair net and staff member KK stated, My hair is struggling today. Yes, I am supposed to cover all my hair with the net.
During an interview on 7/17/25 at 9:10 a.m., staff member GG stated there were hats available for staff who needed help to restrain their hair when a hair net was not enough. Staff member GG stated everyone who works in the kitchen should be supervising hair restraints. Staff member GG stated the main double doors were always propped open to the kitchen. Staff member GG stated she had a sign posted reminding people to restrain hair with nets before entering the kitchen, and stated, “I took them down two weeks ago because people get used to the postings and don’t see them anymore.”
Review of a facility policy titled, Uniform Policy, revised 8/24, reflected:
. 2. Hair Covering; Hats/hair covering will be worn at all times. a. Shall wear hair covering that will cover all hair…needs to be contained in a hair covering or above the collar, this may be a hair net, Logo [facility] caps or bonnet…”
2. During an observation on 7/15/25 at 7:45 a.m., resident #47 was lying in bed, asleep. Staff member U picked up resident #47’s breakfast tray, took the meal tray into resident #47’s room and set it on the bedside table, and left the room.
During an observation and interview at 7/15/25 at 10:50 a.m., resident #47 was sitting at a table in the dining area eating breakfast. Resident #47 stated her breakfast was put in the microwave and given to her. Resident #47 stated it was not very good and cold in some areas.
During an interview on 7/15/25 at 11:02 a.m., staff member U stated meal trays arrived between 7:30 and 7:45 a.m. Staff member U stated if a resident is not awake or up, the meal tray is delivered to the room. Staff member U stated, “When she (resident #47) wants her food we will reheat it for her.” Staff member U stated she did not know there were specific timelines or temperatures with food. Staff member U stated she had never used a thermometer to test food temperature after reheating the meal in the microwave. Staff member U could not verbalize how long a tray could sit out before it was unable to be eaten, or at what temperature the food should be heated to upon reheating.
During an observation on 7/16/25 at 8:55 a.m., staff member R placed resident #47’s meal tray in front of her, took off the lid and buttered the waffle. The butter did not melt on the waffle.
During an interview on 7/16/25 at 8:58 a.m., resident #47 stated her breakfast was cold and the waffle was tough. Resident #47 stated, “It would be better warm.”
During an interview on 7/16/25 at 3:10 p.m., staff member D stated, “Food should not be served to a resident after two hours, anything longer than that is unsafe.” Staff member D stated it was not a standard of practice for nursing staff to be reheating or microwaving food. Staff member D stated, “If a resident is not going to eat right away the tray should go into the refrigerator or staff request a whole new tray when they are ready to eat.” Staff member D stated there was thermometers and food risk information on each unit.
During an interview on 7/16/25 at 4:10 p.m., staff member N stated he had never seen a thermometer or food risk information on the unit.
During an interview on 7/17/25 at 8:35 a.m., staff member E stated staff should not be reheating food for residents. Staff member E stated there was not a thermometer or food risk information on the unit.
Review of a facility document titled, “Food Production Standards,” with an effective date of 5/2025, showed:
. 5. Reheating of foods
a. Food must be reheated to 165 degrees for 15 seconds within two hours.
b. Do not mix leftover food with freshly prepared food.
6. If food is not handled as in above, throw it out.”
Aug 2024
8 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure laboratory personnel in the facility provided privacy during a blood draw, for 1 (#259) of 22 sampled residents. Findi...
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Based on observation, interview, and record review, the facility failed to ensure laboratory personnel in the facility provided privacy during a blood draw, for 1 (#259) of 22 sampled residents. Findings include:
During an observation on 8/27/24 at 8:39 a.m., resident #259 was seated at the middle table, in the open dining room, with a tablemate present, and both were eating breakfast. Three other residents were in the dining room eating breakfast. Unit staff were in the halls next to the open dining room. NF1 and NF2 approached resident #259 and stated they had a STAT order for the resident, as NF1 pulled resident #259 back from the table, and then turned her towards them. Resident #259 was confused and stated, What for, and NF1 replied, It must be for a medication you are on because it is an INR. NF1 applied the tourniquet on resident #259's left arm, and tried to place the left arm on the wheelchair arm, but NF1 did not have the right angle to do the blood draw. NF1 stated the resident's room number to NF2, as she went to grab a pillow from the room, and then placed it under resident #259's left arm. NF2 had gloves on and proceeded to draw vials of blood from #259's arm while in the dining room. No barrier was placed between resident #259's arm or the pillow. Resident #259 grimaced as the needle was placed in her arm. Resident #259's tablemate stopped eating and watched the event, and a resident at another table stopped eating, turned around and watched. NF1, who was barehanded, grabbed the garbage and used supplies from NF2, then placed the vials of blood in an open plastic bag clipped to their mobile cart. NF1 and NF2 walked back to replace the pillow and returned to their cart in the dining room. There were two open bags with two vials of blood each, hung from clips, on the cart. NF2 was still wearing gloves as she grabbed the cart. Resident #259 gave her tablemate a look of incredulity (look of disblief) as she was checking her arm where the blood draw was done.
During an observation and interview on 8/28/24 at 9:50 a.m., resident #259 was teary and confused. Resident #259 stated, I don't know these people. I don't know who they were. They said they needed my blood right now.
During an interview on 8/28/24 at 2:40 p.m., staff member X stated when laboratory staff came over to the unit they automatically went to the resident and scanned their armband before proceeding. Staff member X stated it was up to the resident if they would want to go back to their room or stay out in the common area to complete the laboratory orders. Staff member X stated if a resident was confused they would be able to tell if the resident was comfortable or not to continue in a common area. Staff member X stated she did not know what infection control training the laboratory staff received but they were aware of the facilities enhanced barrier precaution signs.
Review of resident #259's lab results showed she had a prothrombin INR drawn on 8/27/24, by NF1 and NF2, at 8:42 a.m.
Review of resident #259's Residents Rights and Responsibilities form, signed by her responsible party on 8/13/24, showed, .6. PRIVACY. To privacy in accommodation, medical treatment, personal care, and in visits .
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to report an alleged incident of abuse within the required 24 hour reporting period for 1 (#270) of 3 sampled residents for abuse. Findings in...
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Based on interview and record review, the facility failed to report an alleged incident of abuse within the required 24 hour reporting period for 1 (#270) of 3 sampled residents for abuse. Findings include:
A review of the Facility Reported Incident of abuse involving resident #270 showed the incident occurred on 1/17/24. The incident was not reported to the State Survey Agency until 1/19/24. The reporting delay by the staff member did not allow the facility the opportunity to ensure measures were taken for resident protection.
A review of the facility's document, [Resident #270] Abuse Investigation 1/19/24: Incident NOC 1/17/24 shift, showed:
1/19/24 4:00 p.m. [Resident #270] reported to [staff member KK] on 1/19/24 that she wanted to speak to me. [Staff member KK] reported it may be due to rough handling.
During an interview on 8/28/24 at 2:37 p.m., staff member A stated administration was available on the weekends to report incidents to the State Survey Agency. Staff member A said nurses were mandatory reporters.
A review of the facility's policy, Abuse: Definitions, Reporting, Education and Prevention, BH106, last revised 03/2023, showed:
- Policy .
- . 5. It is the responsibility of all staff members to report abuse. It is the responsibility of the [Facility Name] Director of Nursing and Administrator to ensure that this policy and procedure are followed.
- Procedure .
- . 7. Reporting/Response
- . C. Any incidents of alleged abuse or injuries of unknown origin are reported to the Department of Public health and Human Quality Assurance Division Certification Bureau within 24 hours after discovery of the incident .
- Definitions .
- . 4. Identification
- A. All incidents, accidents, and injuries of unknown origin, such as bruising or skin tears and resident-to-resident contacts, are identified through the 24-hour report and event reports in order to initiate an investigation. The Administrator and the Director of Nursing are also notified.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on interviews and record review, the facility failed to protect a vulnerable resident from potential harm during an abuse investigation, for 1 (#270) of 22 sampled residents. This practice incre...
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Based on interviews and record review, the facility failed to protect a vulnerable resident from potential harm during an abuse investigation, for 1 (#270) of 22 sampled residents. This practice increased the risk of other vulnerable residents receiving care from the accused staff member. Findings include:
Review of a Facility Reported Incident, dated 1/19/24, reflected resident #270 reported she was injured by staff member MM during a brief change, and the staff were verbally spiteful just before putting her in bed, because she needed assistance. The report showed staff member MM was reassigned.
Review of the abuse investigation notes for resident #270, dated 1/19/24, reflected the following:
- Resident #270 reported the complaint to staff member OO on 1/17/24, when the incident occurred.
- Staff member OO reported she added the incident ot the alert charing.
- Resident #270 reported the incident again on 1/19/24 to staff member KK.
- The abuse Investigation was started.
- Staff member MM was reassigned to care for other residents.
- Interviews with staff occurred on 1/19/24 - 1/24/24.
- Resident interviews occurred on 1/23/24.
- The follow-up Investigation Report was completed by staff member FF on 1/24/24.
Review of facility timecards for staff member KK reflected she worked on 1/18/24, 1/19/24, 1/21/24, and 1/22/24.
During an interview on 8/28/24 at 1:43 p.m., staff member A stated the facility's policy was to reassign the accused staff member to other residents and start cares in pairs for the resident making the accusation during the investigation. Staff member A stated this had been the facility's practice for years, and she was not aware the accused should not care for other vulnerable residents during an investigation.
During an interview on 8/29/24 at 9:10 a.m., staff member FF stated it was not the current practice of the facility to remove a staff member accused of abuse from resident care. Staff member FF stated it made sense but had not been implemented at the facility yet.
Review of the facility's policy, Abuse: Definitions, Reporting, Education and Prevention, BH106, revised 03/2023, reflected the following:
- . 6. Protection
- A. It is the responsibility of the charge nurse to provide immediate protection to all residents who have had incidents, accidents, and injuries or unknown origin or resident to resident incidents. This may include immediate suspension of the employee .
- B. When an employee is alleged or suspected to have committed an abusive act, the employee may be immediately suspended without pay by the charge nurse pending investigation of the allegations.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
Based on observations, interviews, and record review, the facility failed to provide therapeutic diets to optimize the nutritional status for 2, (#s 25 and 41) of 22 sampled residents. This practice h...
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Based on observations, interviews, and record review, the facility failed to provide therapeutic diets to optimize the nutritional status for 2, (#s 25 and 41) of 22 sampled residents. This practice had the potential to affect any resident at risk for nutritional decline and resulted in severe weight loss for 1 (#41). Findings include:
1. During an interview on 8/27/24 at 8:43 a.m., resident #25 stated, I cannot read so have trouble getting what I want during meals, but if someone reads (the menu) the food is pretty good when I get what I want to eat. Still waiting to get food for breakfast. I keep asking all morning.
During an observation on 8/27/24 at 9:02 a.m., resident #25 was yelling from his bed and could be heard from the hallway. Resident #25 stated, Are they gonna feed me? Staff member S exited the room. Resident #25's food tray was sitting in the dining room on the table uncovered, and untouched.
During an observation on 8/27/24 at 9:06 a.m., staff member U entered resident #25's room and asked resident #25 why his call light was on. Resident #25 stated he wanted to eat, staff member U left the room, leaving light on, then went to another resident room.
During an observation on 8/27/24 at 9:07 a.m., staff member U entered resident #25's room and said someone would be in soon, then turned the call light off, and left the room.
During an observation on 8/27/24 at 9:26 a.m., resident #25's tray was still on the table in the dining room, and his call light was on in his room.
During an interview on 8/27/24 at 9:27 a.m., resident #25 stated the staff had still not given him breakfast. Staff member E entered the room and stated resident #25 could not eat in bed, so he had to wait until after his shower, or the staff would have to feed him in bed. Staff member E stated resident #25 wanted to go to the bathroom, and by the time he went to the bathroom, it would be time for his shower.
During an interview on 8/27/24 at 9:30 a.m., staff member S stated she was not clear on why resident #25 had not been served breakfast. Staff member S stated the staff on the unit were disorganized because she took her daughter to school on the first day, and some staff were new. Staff member S directed staff member E to toilet resident #25 and feed him before his shower.
During an observation on 8/27/24 at 9:44 a.m., staff member B removed resident #25's tray from the dining room table and placed it in the dirty food cart.
During an observation on 8/27/24 at 9:50 a.m., staff member LL entered resident #25's room while resident #25 was yelling, I'm ready (to get off commode). Staff member LL left the room and told staff member E and P resident #25 was ready to get off the commode.
During an observation on 8/27/24 at 9:57 a.m., staff member LL entered resident #25's room and stated, They (CNAs) are getting [resident name] up then they will come.
During an interview on 8/27/24 at 3:51 p.m., resident #25 stated he had two pieces of toast for breakfast at about 10:30 a.m. Resident #25 stated nothing else was offered to him for breakfast.
Review of resident #25's EHR weights indicate resident #25's weights fluctuate related to his diagnosis of Congestive Heart Failure and on-going lower extremity edema.
2. During an observation and interview on 8/27/24 at 9:16 a.m., resident #41 had a open package of cookies on his bedside table, with three cookies gone. Staff member E stated, He's on a puree diet only, he hates it, so he won't eat it. The kitchen always sends puree, so he just eats cookies. Resident #41's breakfast plate was on his bedside table, with approximately two bites gone of the scrambled eggs, which had gravy on them. The meal ticket on the tray reflected the resident was on a soft diet. Resident #25 stated he . won't eat it, it's wet mush.
Review of resident #41's EHR weights reflected the following:
- 5/28/2024: 99.80 kg (219.5 lbs.)
- 8/14/2024: 81.69 kg (179.7 lbs.) which is a -18.13 % weight loss in three months. This is a severe weight loss.
During an interview on 8/28/24 at 10:16 a.m., with staff members A, B, and N, staff member N stated she had changed #41's diet to Benecal protein shakes per his preference, but she had not discussed food preferences with the soft diet to learn what foods resident #25 would likely eat, or specifically why he is not eating the foods brought to him. Staff member B stated #41's wife would bring in many snacks, fast food, and sweets.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure residents received tube feedings as ordered, for 2 (#s 36 and 77) of 22 sampled residents. Findings include:
1. During...
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Based on observation, interview, and record review, the facility failed to ensure residents received tube feedings as ordered, for 2 (#s 36 and 77) of 22 sampled residents. Findings include:
1. During an observation on 8/27/24 at 8:35 a.m., resident #77 was lying in bed, next to the tube feeding pump, which was alarming with the words Feeding complete, across the screen. The tube feeding bag was observed to be over half full.
During an observation on 8/27/24 at 11:25 a.m., resident #77's tube feeding pump was alarming. Resident #77 was in bed, and stated, It drives me nuts (the alarm). The tube feeding pump showed, Error flow clog in line downstream of pump, across the screen.
During an interview on 8/27/24 at 4:19 p.m., staff member Y stated resident #77's pump alarming, earlier in the day, was because the door on the pump, where the tubing came out, was open after it was changed. Staff member Y stated he did not realize if the pump door was open it did not hold the tubing in place to flow, so it alarmed. After the other staff let him know of the alarm, he closed the door and restarted the pump. The pump was running without any problem since that time.
During an interview on 8/28/24 at 10:39 a.m., staff member N stated she checked on residents with tube feedings daily, and residents with tube feeding's were always on the nutrition at risk list. She would get notified of any concerns such as gastrointestinal issues, or if an incorrect tube feed was given, through alerts her supervisor would forward to her. Staff member N stated there had been times residents with current tube feedings were provided the wrong tube feeding than what was ordered. Staff member N stated she would message the nurse who gave the wrong tube feeding, if known, and remind them of the order and supplies to use. Staff member N stated the kitchen had bulk supplies, and the unit ordered tube feeds from the kitchen for the residents and kept them in the medication storage room. Staff member N stated that unless there was an issue of intolerance or major difference in nutrients, she did not get involved more with an event of the wrong tube feeding being given. Staff member N stated nursing would be managing the administration error of the tube feedings.
During an observation and interview on 8/28/24 at 2:26 p.m., staff member X stated the unit now had bins with labels for the different tube feedings on the unit, as there were three currently. She demonstrated how the nurses were to check with the order pulled up on the mobile cart, and then grabbed Isosource 1.5 for resident #77. Staff member X stated she let the current feed run dry and had just turned the alarm and pump off to change out a new tube feeding. Staff member X stated the alarming for resident #77's pump was now part of her environment and did not bother the resident. Staff member X stated the tube feed times for resident #77 varied because of the tube feeding, bolus of fiber and medications given, and if the resident wanted to get up or lay down flat. Staff member X stated if there was an issue with the tube feeding for a resident she would stop the tube feed, contact the provider for a directive and assess the resident.
During an interview on 8/29/24 at 8:55 a.m., staff member Z stated resident #36 had an updated order to five times a day bolus feed versus resident #77 with a continuous feed. Staff member Z stated the nurses were training resident #36's family how to do the tube feeding for her. Staff member Z stated he had used the type of tube feeding pumps of the residents for a long time, but had not had any training on tube feeding in years.
During an interview on 8/29/24 at 9:10 a.m., staff member FF stated there had been issues with tube feedings for residents. It was an area they were working on correcting. Staff member FF stated the incorrect tube feedings for residents #77 and #36 were treated like a medication error, for not following the orders. Staff member FF stated when the nurse who administered the wrong tube feedings was able to be identified he would educate them on the proper tube feeding orders. Staff member FF stated the facility management thought it was because the supplies looked so similar, but then a nurse grabbed the wrong bag after they were all labeled. Staff member FF stated new hires have to do a competency on tube feedings, if there is a resident in the facility at the time who was tube fed. There had not been any other training's on tube feeding for staff, but a training that was needed due to the errors occurring.
Review of resident #77's hard copy EHR showed a note on 8/14/24, This RN observed the Pt taking in Fibersource HN through her tube feed instead of Isosource 1.5. No adverse effects observed. Please advise. On 8/16/24 a response from a provider showed, Will review .
Review of resident #77's current diet orders showed, Tube Feeding Diet, Isosource 1.5 cal by gastric tube with a goal rate of 60 ml per hour.
2. Review of resident #36's hard copy EHR showed:
- 8/23/24, This RN accidentally gave an additional dose/bolus of Fibersource HN on 8/22/24 @ approximately 2300 (11:00 p.m.) No adverse effects observed. Please advise. Midas conducted. Will continue to monitor . (Was approximately 300 ml).
- 8/24/24, Pt was found to have received the wrong tube feed - Isosource 1.5 rather than Fibersource HN. [No] adverse effects noted so far.
Review of resident #36's current diet orders showed, Tube Feeding Diet, Fibersource HN, bolus feeding 250 ml bolus five times a day with flush before and after feeds.
Review of an email thread about tube feedings, provided by the facility, showed:
- Starting on 8/8/24 tube feeding errors were identified and a discussion of corrective options and reasons for the errors began.
- A screen shot of the Glacier pod tube feeding supplies on 8/23/24 were labeled with the residents orders and in bins to separate the different types.
- Emails sent to two nurses who made errors in giving the wrong tube feedings to residents #77 and #36 were also in the provided information.
Review of the Glacier pod, August 2024, events, showed errors for #77 on 8/14/24, and for #36 on 8/22/24 and 8/24/24, however it did not show what was done to prevent future tube feeding errors.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected multiple residents
Based on interviews and record review, the facility failed to notify the physician and family of a significant weight loss for 1 (#19); and a severve weight loss for 1 (#52) of 22 sampled residents. F...
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Based on interviews and record review, the facility failed to notify the physician and family of a significant weight loss for 1 (#19); and a severve weight loss for 1 (#52) of 22 sampled residents. Findings include:
1. Review of resident #19's EHR weights reflected the following:
- 7/6/24: 64 kg (140.8 lbs.)
- 8/3/24: 60.9 kg (133.98 lbs.) for a 5.09% weight loss in one month, a significant weightloss.
During an interview on 8/26/24 at 4:28 p.m., staff member S reviewed the hard copy chart and EHR of resident #19 and stated she could not locate any notifications to the physician for the weight loss. The last dietician note was dated 6/11/24. Staff member S stated resident #19 required assistance with feeding herself, including cueing, and redirection.
During an interview on 8/27/24 at 10:15 a.m., staff member N stated resident #19 received a boost nutritional drink with meals. Staff member N stated resident #19's weight loss was mentioned in the nutrition at risk meetings, but she did not have notes to reflect a visit, or further interventions done since the weight loss. Staff member N stated the resident care managers were the ones who notify the physicians and families for changes.
2. Review of resident #52's EHR reflected the following weights:
- 2/21/24: 85.7 kg (188.54 lbs.)
- 7/28/24: 74.2 kg (163.24 lbs.)
- 8/21/24: 71.0 kg (156.20 lbs.) for a 17% weight loss in six months, a severe weightloss.
During an interview on 8/26/24 at 4:28 p.m., staff member S reviewed the hard copy chart and EHR of resident #52 and stated she could not locate any notifications to the physician or family for the weight loss. Staff member S stated the last documentation in the hard copy record was dated 2/6/24. The nutrition at risk documents had been completed, but the notification to the physician and family sections were left blank.
During an interview on 8/29/24 at 9:12 a.m., with staff members A and B, staff member B stated the last notification for weight loss for resident #19 was in February (2024). Staff member B stated residents are discussed in all of the Nutrition at Risk meetings; however, the physicians were not a part of those meetings. Staff member B stated she would locate the notifications to the physician and fax them after the survey. At the end of the survey, the facility was provided a specific time in which all documentation must be submitted. The facility did not provide any further information.
Review of the facility's policy, Weight/Nutrition at Risk, BH320, revised 01/2023, reflected:
- .2. All significant changes in weight (5% in 30 days; 10% in 180 days), as defined in Centers of Medicre and Medicaid Services (CMS) interpretive guidelines, will be reported to the patients/resident's provider and responsible party. Consultation with a RD will be obtained as needed. [sic]
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
2. During an observation of the dining room breakfast meal service, on 8/28/24 at 8:22 a.m., staff member G carried a breakfast tray from the steam table into a resident room. Staff member G returned ...
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2. During an observation of the dining room breakfast meal service, on 8/28/24 at 8:22 a.m., staff member G carried a breakfast tray from the steam table into a resident room. Staff member G returned to the steam table for the next meal tray, was observed brushing her forehead and hair with her hand, and then carried a meal tray to another resident in the dining room. Staff member G peeled the resident's banana, removed the food covers, handled the resident's utensils, and touched the resident's right arm and wheelchair handle. Staff member G then returned to the steam table two additional times to pick up and deliver trays to different residents in the dining room. Staff member G was observed touching the tables, the residents' hands, and their utensils. Staff member G did not perform hand hygiene at any time during the dining room observation period.
During the same observation of breakfast meal service on 8/28/24 at 8:22 a.m., staff member E was observed wearing the same pair of gloves while assisting multiple residents with meal service. Staff member E was observed touching one resident, their wheelchair, meal tray, food, and utensils, and then assisting other residents with their meal trays. Staff member E did not change gloves or perform hand hygiene between assisting residents in the dining room.
During an interview on 8/28/24 at 1:50 p.m., staff member A stated staff should be performing hand hygiene at every point of contact with residents.
Review of a facility policy titled, Hand Hygiene, IPC104, revised 5/2022, showed the following:
- .1. When to perform hand hygiene .
- . B. Immediately after each episode of direct patient contact/care
- . D. Immediately after contact with objects and equipment in the immediate patient environment or other activities that could result in hands becoming contaminated.
- E. Immediately after removal of gloves, including between the exchange of dirty to clean gloves.
Review of the CDC.gov document, titled, Clinical Safety: Hand Hygiene for Healthcare Workers, accessed on 8/28/24, included the following information:
Hand hygiene should be performed:
- . Immediately before touching a patient,
- . after touching a patient or patient's surroundings .
- When healthcare providers do not perform hand hygiene 100% of the time, they put themselves and their patients at risk for serious infections.
Based on observation, interview, and record review, the facility failed to ensure proper staff hand hygiene was used during meal service in a common dining room; failed to ensure proper hand hygiene was used when delivering meal trays to resident rooms, for 6 (#s 16, 25, 46, 52, 61, and 70); and failed to ensure laboratory personnel followed infection control practices during a blood draw for 1 (#259) of 22 sampled residents. Findings include:
1. During an observation on 8/28/24 at 7:32 a.m., staff member E took resident #61's meal tray to his room, started to set up resident #61 in bed by adjusting the pillows, changing the bed position with the remote, and removing personal items on the bed. Staff member E left the room to get a clothing protector from the cabinet in the dining room. No hand hygiene was performed by staff member E as she exited the room. Staff member E went to the nutrition room, made a cup of coffee for resident #61, stocked cups, and then returned to resident #61's room to set up the meal tray. Staff member E placed the food protector on resident #61, and opened and buttered the waffles. Staff member E left the room without completing hand hygiene, went to the food service line, grabbed resident #70 a fruit bowl, stopped at the dining room cabinet for sugar packets, and returned to the residents' room. Staff member E placed the fruit bowl on resident #70's tray and determined he also needed sugar, wiped her hands on her scrub bottoms, and returned to the dining room cabinet for the sugar substitute packets. Staff member E again wiped her hands on her scrubs, returned to the resident's room, gave resident #70 his sugar packets, and then returned to resident #61 to add sugar to his food. Staff member E then left the resident's room without completing hand hygiene, then returned to the food serve line and began prepping food items for the next resident tray. Staff member E entered the room of the next resident without completing hand hygiene.
During an observation on 8/28/24 at 7: 34 a.m. staff member U entered the room of resident #70, setup his tray and exited the room without completing hand hygiene. Staff member U returned to the food service line and began prepping items for the next resident tray.
During an observation on 8/28/24 at 7:50 a.m., staff member Q took resident #16's tray to his room, started setting up his tray and bed. Resident #16 asked for salt and staff member Q exited the room without completing hand hygiene, went to the nutrition room for salt, returned to the room and assisted with tray set up. When staff member Q left the room, she did not complete hand hygiene and returned to the food service line and began prepping items for the next resident tray.
During an observation on 8/28/24 at 7:53 a.m., staff member E entered resident #52's room and placed the meal tray on his bedside table. Staff member E began getting resident #52 ready to pull up in bed, and stated she was waiting for another CNA to assist with positioning resident #52. Staff member E lowered the bed down flat, adjusted the pad under resident #52's buttocks, adjusted his blankets, and moved clean linens from the chair to the sink. Staff member V arrived, put on gloves, and assisted with sliding resident #52 up in bed, then left. Staff member E set up the meal tray and began to feed resident #52, then stopped and left the room. Staff member E went to get butter and sugar from the dining room cabinet without completing hand hygiene. Staff member E returned to the resident's room and re-started the setup of resident #52's tray with butter and sugar, then started feeding the 1 to 1 feeding again.
During an observation on 8/28/24 at 8:28 a.m., staff member F entered resident #46's room carrying a breakfast tray. Staff member F was in resident #46's room for four minutes assisting the resident with positioning and setup for the meal. Staff member F exited the room at 8:32 a.m. without performing hand hygiene and walked to the nourishment room door. Staff member F entered the code on the locked door, walked into the nourishment room, obtained a drink for resident #46, and returned to the resident's room. No handwashing or hand sanitizing was performed until 8:37 a.m., after staff member F left resident #46's room for the final time, and then returned to the dining room.
During an observation on 8/28/24 at 12:37 p.m., staff member E entered resident 25's room and placed a food protector on the resident. Staff member E then adjusted him in bed, put on gloves from her pocket without performing hand hygiene, put food condiments on his burger, cut the burger in half, took her gloves off, placed the meal tray on his pillow in his lap, and left the room without completing hand hygiene. Staff member E returned to the food service line and began prepping meal items for the next resident tray.
3. During an observation on 8/27/24 at 8:39 a.m., resident #259 was seated at the middle table of the open dining room with a tablemate, both were eating breakfast. NF1 and NF2 approached resident #259 and stated they had a STAT order for her. NF1 tied off resident #259's left arm and grabbed a pillow from her room and then placed it under resident #259's left arm. NF2 was gloved and proceeded to draw vials of blood in the dining room. No barrier was placed between resident#259's arm or the pillow. NF1 barehanded, grabbed the garbage and used supplies from NF2 and placed the vials of blood in an open plastic bag clipped to their mobile cart. NF1 and NF2 walked back to replace the pillow and returned to their cart in the dining room where two open bags with two vials of blood each hung from clips. NF2 was still wearing gloves as she grabbed the cart.
During an interview on 8/29/24 at 8:45 a.m., staff member Z stated the laboratory staff followed the precautions signs when they had them on the resident doors but did not know of any specific infection control training they received.
During an interview on 8/29/24 at 9:07 a.m., staff member FF stated the laboratory staff cart had all the supplies such as chucks as a barrier in case of the resident bleeding but could use the units supplies if needed. Staff member FF did not know what training the laboratory staff received but they did follow the precautions signs on resident doors when entering them.
Review of resident #259's laboratory results showed she had a prothrombin INR drawn on 8/27/24 by NF1 and NF2 at 8:42 a.m.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observations, interviews, and record review, the facility staff failed to wear hair restraints or wear them properly during food preparations to prevent hair from entering the food, which inc...
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Based on observations, interviews, and record review, the facility staff failed to wear hair restraints or wear them properly during food preparations to prevent hair from entering the food, which increased the risk of hair falling in the food served to the residents. Findings include:
During an observation on 8/26/24 at 3:15 p.m., staff member H was preparing drinks at the prep table with her hairnet only covering a hair bun on top of her head. The hairnet did not cover her bangs, or her hair below the bun. Staff member I had no beard net, but had a full beard, and was working on the cook line. Staff member J was prepping fruit bowls with her hairnet on but it was only covering the top third of her hair. Staff member K was prepping fish with her hairnet on but it was only covering the top one-third of her hair. Staff member K's long bangs hung down to her eyebrows and were not covered. The sides and back of her hair was not covered.
During an interview on 8/26/24 at 3:30 p.m., staff member L stated staff members H, I, J, and K were not in compliance with the facility's hair restraint policy, and she would be re-educating them immediately.
During an observation on 8/27/24 at 1:03 p.m., staff member GG was standing on the cook line with his beard net hanging off one ear and not covering his full beard. Staff member BB was on the prep line making a tray with her hairnet not covering her hair hanging down. Staff member HH was standing at the prep line talking to other staff members with hair not covered fully by a hairnet. Staff member II was moving clean dishes to the serving line with her ponytail hanging outside of the hairnet. Staff member JJ walked thru the prep line in the kitchen wearing her hat with loose bun dangling out the back down to her shirt. Staff member JJ stated, I was told I didn't have to wear a hairnet for sloppy buns, only if hair is fully down.
During an interview on 8/27/24 at 1:23 p.m., staff member L stated, Education was done (with kitchen staff), and they should all have their hair fully restrained.
During an observation on 8/28/24 at 8:12 a.m., staff member I had no beard net on while standing on the cook-line. Staff member EE had no hairnet on while on the cook-line. NF4 and NF5 arrived in the kitchen with a new oven and rolled the oven through the cook-line without hair restraints. Staff member M was pushing a cart through the cook line with no hairnet covering the bottom half of her head, with her hair hanging down, unrestrained.
Review of the facility's Uniform Policy, revised 05/19, reflected:
. Vi) Shall wear hair covering that will cover all hair, hair needs to be contained in hair covering or above collar, this may be a hairnet, Logo caps or bonnet.
.Vv) .Beards or mustaches longer than 1/2 inch will require a beard covering while in the kitchen or service areas.
Sept 2023
7 deficiencies
2 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Pressure Ulcer Prevention
(Tag F0686)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to prevent and provide services necessary to promote hea...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to prevent and provide services necessary to promote healing on one facility acquired pressure ulcer for 1 (#62), and the wound was Unstageable, tunneling, and difficult to heal, of 23 sampled residents. Findings include:
During an observation on 9/12/23 at 9:28 a.m., resident #62 was in his bed in low fowler's position (head slightly elevated), with no positioning devices or pillows except one pillow under his head.
During an observation at 9/12/23 at 2:08 p.m., resident #62 was in his bed in low fowler's position, with no positioning devices or pillows except one pillow under his head.
During an observation on 9/12/23 at 2:18 p.m., staff members I, L, and N entered resident #62's room to complete wound care, and check and change the resident's brief. Resident #62 was in low fowler's position. Staff member I removed the sacrum wound dressing, and found feces up to, and in, the sacrum wound. The sacrum wound was cleaned and measured, and staff member I stated the sacrum wound was, 3.5 cm x 2.5 cm with tunneling all over and it's hard to get it all washed out when BM gets in there. The wound was irrigated with Vashe liquid, and the staff waited five minutes to proceed as directed in the order. At 2:37 p.m., staff member I applied Medi honey with the applicator of the bottle touching entrance of the wound, squeezed it into the wound, and around the outside of the sacrum wound. Staff member I then applied an abdominal pad across the buttocks and taped on the outside of the right and the left buttock. The sacrum wound bed was exposed at the bottom of the dressing, allowing future bowel movements to potentially enter the wound bed. Staff member I stated to staff member L, There is redness to the inside of his knees, please place pillow between his knees and place [Resident #62] on his side. Resident #62 stated he had no pain during the positioning, and the dressing change. Resident #62 had redness from his rectum to his scrotum, that was not treated during the observation. Resident #62 was then turned back onto his back, with a gown and brief put on. Resident #62 was then positioned in low fowler's position with a pillow under and between his knees by staff member N.
During an interview on 9/12/23 at 2:50 p.m., staff member M stated, Oh yeah, we usually use triad cream on redness on his scrotum. But I don't think the sacral wound order is very good, we can't keep the BM [feces] out. Yesterday the nurse said she found a lot of BM in the wound and had to do a lot of irrigation. So that's two days that I know of. I didn't like the order a month ago when all they were doing was triad cream. I felt like it needed Medi plex and more aggressive treatment then. If I don't like the order I can go to [staff member J], I'm not really comfortable talking to the wound nurse yet. I've only been here since April. But I can talk to [staff member J]. The wound nurse is a PA. I've only ever even seen her once. I haven't gone to [staff member J] on this one, because I figure the wound team is on it, I guess.
During an interview on 9/12/23 at 2:58 p.m., staff member J stated, Usually if the nurse has concerns, they can send the doctor a Volt [secure messaging system] message. Usually, they do so directly, or they can come to me.
During an observation on 9/13/23 at 7:57 a.m., resident #62 was in bed, in low fowler's position, with a pillow under his right shoulder to his hips, facing the wall. There were no pillows between his knees.
During an observation on 9/13/23 at 8:09 a.m., resident #62 was in his bed in high fowler's position (slightly declined upright), with his bedside table over the bed, in front of him.
During an observation on 9/13/23 at 11:17 a.m., resident #62 was in his bed, in low fowler's position, with a pillow between his knees.
During an observation on 9/13/23 at 11:49 a.m., resident #62 was in his bed, in low fowler's position, with a pillow between his knees.
During an observation on 9/13/23 at 4:06 p.m., resident #62 was in his bed, in low fowler's position, sleeping. No pillow was present.
During an interview on 9/13/23 at 4:07 p.m., staff member O stated, when a resident was to be repositioned every two hours, We just move the pillow from one side to the other side. Staff member P stated, We move the pillow to the opposite side back and forth every two hours. And pull them up in bed if necessary. Staff member Q stated, We just keep moving the pillows side to side. Staff member R stated to staff member Q, What you really should be doing is turning him all the way on his side, and putting a pillow between his knees so he is off his butt.
During an interview on 9/14/23 at 7:56 a.m., staff member S stated she would expect resident #62 to be turned completely on his side because he has a sacrum wound.
During an interview on 9/14/23 at 8:56 a.m., staff member A stated she could not provide the documentation of any VOLT messages, regarding resident #62, sent to the physician requesting wound dressing changes to decrease feces from entering the wound.
A review of resident #62's medical record reflected the following:
- Resident #62 was admitted to the facility on [DATE].
- Resident #62 developed a deep tissue injury on 7/31/23, approximately 5 cm x 9 cm, on the sacrum.
- An order was placed on 8/2/23 for an air mattress, which the admitting care plan, dated 5/14/21, reflected as an intervention already in place, and a Medi plex dressing over the wound.
- Resident #62 was seen on 8/14/23. Staff member V noted, Certainly some degree of pressure played a role in this skin injury .keep dry and offload as possible .2cm x 3cm ulcer of the sacrum; equivalent to a stage 3. An order was placed on 8/14/23 for betadine to buttock ulcer two times daily, with no special dressing.
-On 8/16/23 staff member T noted, Sacrum with unstageable pressure injury. Nursing staff to maintain pressure injury prevention measures.
- On 9/7/23 staff member U noted, .without 90g of protein, offloading, this will likely no heal. Struggling to do both .Sacral wound Stage IV nearly to bone certainly down to deep tissue and ligaments surrounding this area. No undermining in every direction .[sic]
- Wound measurements were documented on 9/9/23 at 11:45 a.m. as 2.5 cm x 3.5 cm x 1.5 cm.
Review of resident #62's Actual Skin Problem Care Plan, dated 5/24/23, reflected resident #62 admitted to the facility with the following pressure ulcers: Stage I to the right lateral ankle and Stage II to the left upper buttock. The document reflected the buttock wound was resolving. The care plan interventions included the following:
- Position off area
- Pressure re-distributing mattress: Atmos Aire 4000
A review of the facility's Mattress Overlay request form, dated 8/2/23, reflected the Air Mattress was placed on resident #62's bed on 8/2/23.
Review of resident #62's Actual Skin Problem Care Plan, dated 8/21/23, reflected resident #62 had a Stage IV pressure ulcer to the sacrum.
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Deficiency F0692
(Tag F0692)
A resident was harmed · This affected 1 resident
Based on observation, interview, and record review, the facility failed to maintain an adequate nutritional status for 1 (#62), resulting in a severe weight loss; and failed to provide a physician ord...
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Based on observation, interview, and record review, the facility failed to maintain an adequate nutritional status for 1 (#62), resulting in a severe weight loss; and failed to provide a physician ordered therapeutic diet for 1 (#66) of 23 sampled residents.
1. During an observation on 9/12/23 at 9:22 a.m., resident #62 was in his bed in low fowler's position (head slightly elevated) and stated he was unable to reach his water on the bedside table.
During an observation and interview on 9/12/23 at 2:09 p.m., staff member L was in resident #62's room assisting with a bed bath and wound dressing change. Staff member L stated resident #62, is not wanting food lately but loves the shakes, boost, I think. So, I offered him a bite of strawberries but he said no earlier. He drank the shake. He didn't eat last night either. He eats independently, but he's my buddy so I come and encourage him.
During an observation on 9/13/23 at 7:57 a.m., resident #62 was in bed, in low fowler's position, with a pillow under the right shoulder to the hips, facing the wall. There were no pillows between his knees. Resident #62's meal tray was on the bedside table, approximately three steps away from the bed, out of reach for resident #62.
During an observation on 9/13/23 at 8:00 a.m., staff member L entered resident #62's room to offer food to resident #62. Staff member L was talking to him while offering bites of sausage. Staff member L left the room to get drinks. Staff member L gave him a shake, cranberry juice, coffee, and milk. Staff member L left the room with the meal tray set-up in front of the resident.
During an observation on 9/13/23 at 8:09 a.m., resident #62 was in high fowlers position (slightly reclined), with his meal on the bedside table. The bedside table was over the bed, in front of resident #62. There were no staff present in the room. Resident #62's hands were contracted, with a tremor present. Resident #62 was attempting to drink cranberry juice from a cup. Resident #62 was fidgeting with the cranberry juice cup, nearly tipping the cup onto himself. Resident #62 continued to hold onto the cup rim while the cup remained on the tray, making multiple attempts to pick up the cup, without success. There was no food eaten during this observation period.
During an observation on 9/13/23 at 8:33 a.m., resident #62 was in bed with the bedside table in front of him. Cranberry juice was spilled on his clothing, bedding, and the cup was lying in the bed. One bite of sausage was gone from the tray, and no other items appeared eaten.
During an interview on 9/13/23 at 8:45 a.m., staff member L stated, He's (resident #62) not eating except the bites I give him. Not sure if it is just him pleasing me or what. His hands are really shaky, and I noticed he spilled his cranberry juice all over himself.
During an observation on 9/13/23 at 8:51 a.m., resident #62 was watching television, with the bedside table over the bed in front of him. Resident #62 was chewing the piece of sausage staff member L had given him. Resident #62 attempted to grab his milkshake on the tray, with his eyes closed, and his hands were tremoring. One quarter of his milkshake was gone, and one bite of sausage was eaten when the tray was picked up.
During an interview on 9/13/23 at 9:00 a.m., staff member K stated resident #62 was on the 'at risk for weight loss' list. Staff member K had ordered mighty shakes to be given three times daily because of the pressure injury. Staff member K stated her expectation would be staff feeding resident #62. Staff member K stated the last dietary assessment was on 8/15/23 and showed resident #62 was independent with meals. Staff member K stated, based on observation, she thought he needed assistance with meals. Staff member K stated she thought the facility should move resident #62 to a total assist with feeding at the bedside. Staff member K placed an order to change resident #62's meals to total assistance at the bedside.
During an interview on 9/13/23 at 1:16 p.m., staff member Y was in resident #62's room feeding him. Staff member Y stated, [Resident #62] ate great today. He just doesn't like the squash. Resident #62 was eating his meal, as staff member Y fed him. The plate of food was nearly gone.
During an interview on 9/14/23 at 9:02 a.m., staff member L stated, He ate six bites of waffles, half of a link sausage, four bites of oatmeal, one bite of fruit, and all his milkshake. I had to help him totally. He couldn't do it on his own. He couldn't even pick up his milk.
Review of resident #62's EMR weights reflected:
- 3/5/23 weight 189.86 lb.
- 6/3/23 weight 179.3 lb.
- 8/8/23 weight 172.83 lb.
- 9/7/23 weight 168.52 lb.
This data reflected a severe weight loss of 21.34 lbs. for a 12.6% weight loss over a six-month period.
2. During an interview on 9/13/23 at 8:37 a.m., resident #66 stated he wanted food. Meal trays had been passed. Staff member I stated, He (resident #66) is NPO, we don't feed him anymore.
During an interview on 9/13/23 at 9:47 a.m., staff member Z stated, [Resident #66] is someone I have seen repeatedly. His family wanted him fed. His sister is a great advocate but now it has changed to his daughter as the POA. His sister brings someone in to work with him on exercises. These orders are the current expectation. [Resident #66] says he wants to eat. I've educated him on the aspiration risk. His daughter is the POA and said do whatever he wants. I also educated her on the risks. I worked with him for several days to determine the safest food texture and technique. I didn't want to just give an order for three meals a day. I educated the nurses that he can have pureed meat, potatoes, and anything pudding textured with a maximum of two ounces at a time. As the therapist I write the order. I do not put the order in the computer, I went over the order with [staff member J] and gave her the order. Staff member Z stated resident #66 had been treated as NPO because of the order not having been followed since written on 6/30/23. The oral food order was for comfort, per resident #66's request.
During an interview on 9/13/23 at 9:56 a.m., staff member J stated, Nurses are supposed to put orders in Meditec, put it on the pocket care plan, and we have another nurse review the order as a second check.
During an interview on 9/13/23 at 3:38 p.m., staff member A stated resident #66's oral feeding was something his sister brought up, and he needed to be in the proper position to be able to even have any food at all. It was really only for his enjoyment, and if there was a diet order, he would be getting a full tray all the time, which would not be good for him either. Staff member A did not have an answer for why oral food intake was ordered twice on paper, and never put in the computer. Staff member A stated order processing had not been a QAPI concern.
Review of resident #66's EMR reflected no order placed in active orders, or history for oral intake, per the speech therapist's orders written on 6/30/23 and again on 7/14/23.
Review of resident #66's Physician's Orders, dated 6/30/23, reflected the following:
-Patient may have limited PO intake for quality of life .
Review of resident #66's Physician Orders, dated 7/14/23, reflected:
-Continue previous feeding orders (6/30/23). Nursing staff only may feed upright in bed .
Review of resident #66's Physician SNF: Progress note, dated 8/23/23, reflected, Continue tube feedings and oral intake for comfort .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0624
(Tag F0624)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to provide sufficient preparation and orientation to a resident to ensure a safe discharge from the facility by discharging the ...
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Based on observation, interview, and record review, the facility failed to provide sufficient preparation and orientation to a resident to ensure a safe discharge from the facility by discharging the resident to the front yard of a charity building, with no means of shelter, for 1 (#126) of 27 sampled residents. This deficient practice had the potential to cause the resident psychosocial harm, resulting in the resident crying and feeling distraught. Findings include:
During an interview on 9/13/23 at 12:13 p.m., staff member W stated, I was simply asked to reassure him (resident #126) that he can still see me at the clinic. I was the one who wanted him admitted here. I really don't understand why they are discharging him. Family in the area is on again, off again, and he is in a homeless status. Interesting question (Why is he being discharged ?), I was told he was not following rules. He could use some support but not sure it is this level, but don't have the middle ground to somewhere that checks on him taking medications etc. He's homeless so no home health option. Two weeks ago, he was in the ER four times in a month and was assaulted. He's going back to the same situation he was in.
During an observation and interview on 9/13/23 at 12:15 p.m., resident #126 was walking down the hall and walked by the conference room where the survey team was meeting. He was escorted by a security officer and another staff member was pulling a cart with resident #126's belongings. Resident #126 stated, I don't have any place to put my stuff, I already told you that.
During an observation and interview on 9/13/23 at 12:23 p.m., the security officer was walking back to the facility pulling an empty cart and stated they took him (resident #126) to the [Charity Name].
During an observation on 9/13/23 at 1:21 p.m., resident #126 was sitting on the ground in the front yard of the [Charity Name] with four plastic bags placed around him.
During an interview on 9/13/23 at 1:25 p.m., NF1 stated that [Charity Name] does not provide housing, and the facility only provided a place for homeless people to take a shower and get lunch, no other meals were served at the facility. NF1 further stated that resident #126 was crying and distraught when he talked to him after he showed up on the premises and NF1 gave him a bag to put his belongings in.
During an observation and interview on 9/13/23 at 1:30 p.m., resident #126 was standing in the front yard of the [Charity Name] with four filled up, plastic bags scattered around him, and stated, facility staff told him that he was being discharged because he stole a computer and bullied other people to give him money and then, They brought me to [Charity name] and said I'm on my own. Resident #126 began to cry, and stated he had gotten rid of his tent, stove and sleeping bag because, They said I could stay at the facility until I found a place, I've got no place to go, no sleeping bag and no phone. Resident #126 further stated, I'm probably going to get assaulted again and I hope someone gets me in the neck because I got no place to go.
During an interview on 9/13/23 at 3:50 p.m., staff member AA stated resident #126 had burned every bridge with regards to other placements. The facility reached out to [Facility name] and they stated they evicted him last time he was there, and they declined accepting him back. Staff member AA stated resident #126 was fixated on where he was supposed to go, but he was homeless before he came to the facility, and it was approached that he was being discharged to his prior setting. The discharge team felt they needed to assist him in some way and the [Charity Name] gives him a place to 'light' (settle) and buy him time. [Charity Name] does meals, breakfast, and lunch, I think. That seemed like a great plan .[Resident #126] was told, I think, (him coming to the facility) was a stop gap to get him off the street. Staff member AA further stated there was no official orders at the time of his discharge, but that facility staff went over his belongings with him.
During an interview on 9/14/23 at 8:20 a.m., staff member BB stated when the facility discharged a resident to home, the facility identified the resident was ready to go and checked for supports, family, etc., the facility made sure it was a safe discharge. Resident #126 was homeless when he was admitted to the facility. Staff member BB stated resident #126 was not following the rules of the facility, and his roommate, resident #11, feared him, and resident #11 did not want to move into another room. Resident #126 violated the rules by taking an iPad from therapy the first day he was here, and he was suspected of taking an iPad from a resident was well. Staff member BB further stated resident #126 told her he wanted to go to [Assisted Living Facility name] and his long-term goals were, Getting back on his own feet, and the facility tried to do that. Staff member BB said she was supposed to talk to [ALF staff name] or [ALF staff name] at [Assisted Living Facility name] that day. When questioned by this surveyor, Why did the facility wait to discharge him until she spoke with [Assisted Living Facility name staff] today, and discharged him yesterday? Staff member BB stated, I didn't make the decision to discharge resident #126 yesterday.
During an interview on 9/14/23 at 10:10 a.m., staff member A stated resident #126's discharge was a planned medical discharge, so he did not need to be offered an appeal.
A review of a facility policy titled, Discharge Planning TCU & LTC, with a last revised date of 12/2021, showed:
Purpose
To provide a discharge planning process which utilizes quality standards of practice through a continuum of care to assure maximum preparedness and ensure safe and timely discharges.
Policy
1. The discharge planning process will utilize quality standards of practice through a continuum of care to provide maximum preparedness and safe and timely discharges .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to care plan a resident's need for visitors to check in with the nurse's station before entering his room, related to behaviors ...
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Based on observation, interview, and record review, the facility failed to care plan a resident's need for visitors to check in with the nurse's station before entering his room, related to behaviors of having inappropriate items and substances brought in, for 1 (#82) of 27 sampled residents. Findings include:
During an observation on 9/11/23 at 4:00 p.m., a red laminated sign was taped to the door frame of resident #82's room. The sign showed to go to the nurse's station before entering the room of resident #82 and his roommate. The sign did not indicate which resident it was meant for.
During an interview on 9/13/23 at 2:58 p.m., staff members EE and DD stated the 'stop at nurse's station' sign was for resident #82, due to visitors bringing inappropriate items to him. Staff member EE stated managing his visitors would not be something they care planned or tracked, staff were to just make sure they did not bring items to him without being reviewed by facility staff. Staff member EE stated resident #82 had a telesitter soon after his admission due to the inappropriate items and behaviors, but the telesitter had been discontinued.
During an interview on 9/14/23 at 8:23 a.m., staff member FF stated the CNA's used a shorthand care plan to know what to do for the residents each day, but it did not have any information regarding resident #82's behaviors or visitors. Staff member FF stated nursing shift report was how they informed each other of the 'check in at the nurse's station' sign was for resident #82 and any prior incidents. Staff member FF stated resident #82 had not had any issues mentioned in shift report in several weeks, but it would have been dealt with by the nurses on duty. Staff member FF stated the sign was more for the resident not wanting certain visitors.
Review of resident #82's nurse progress notes showed:
- 7/6/23, An orange straw with a white substance was found in bed when pt was being changed. Pt states that they were for his juice boxes.
- 7/11/23, .checked Pt's fast-food bag and found a box of Alka Seltzer in the bag.
- 8/13/23, noted a visitor today who came and left x3 separate occasions but only stayed for <10 minutes at a time . The visitor came after this [liquid oxycodone] was given sometime between 1700 [5:00 p.m.] and 1730 [5:30 p.m.] Around 1800/1815 [6:00p.m.] during safety rounds, patient was noted to be extremely somnolent, and not arousable to verbal stimuli . Provided noxious stimuli and patient aroused . Resident #82 denied taking other substances, and the provider ordered to monitor every hour for a few hours.
- 8/16/23, CNA brought a green sharpie paint pen to me stating it was a weapon. CNA took the cap off exposing a blade where the felt tip should be.
- 9/12/23, .Observed from the nurse's station, a female [visitor name] and a male swiftly entered patient's room without checking in . The red sign hung outside patient's room stating 'stop at nurse's station before entering' was made apparent to the visitors . An explanation behind this decision given to patient, which included history of events post suspicious visitors, the behaviors of his visitors at this time, and possibly ill intentions for this visit. Patient did not deny .
Review of resident #82's Care Plan, provided on 9/13/23, showed no areas or interventions related to the resident having visitors bringing in inappropriate items, or the residents behaviors with his medications and other paraphernalia, or when and why the red sign was implemented. The only care plan area regarding resident #82's items was, Need to Secure Valuables per [resident #82's] Choice.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0660
(Tag F0660)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to implement an effective and safe discharge planning process that would effectively transition the resident to post-discharge c...
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Based on observation, interview, and record review, the facility failed to implement an effective and safe discharge planning process that would effectively transition the resident to post-discharge care, and failed to involve the resident in the development of the discharge plan, for 1 (#126) of 27 sampled residents, which resulted in the resident becoming homeless, and 1 (#11) became involved as the room mate and he was upset with #126. Findings include:
During an interview on 9/13/23 at 12:13 p.m., staff member W stated, I was simply asked to reassure him (resident #126) that he can still see me at the clinic. I was the one who wanted him admitted here. I really don't understand why they are discharging him. Family in the area is on again, off again, and he is in a homeless status. Interesting question (Why is he being discharged ?), I was told he was not following rules. He could use some support but not sure it is this level, but don't have the middle ground to somewhere that checks on him taking medications etc. He's homeless so no home health option. Two weeks ago, he was in the ER four times in a month and was assaulted. He's going back to the same situation he was in.
During an observation and interview on 9/13/23 at 1:30 p.m., resident #126 was standing in the front yard of the [Charity name] with four filled up, plastic bags scattered around him, and stated, facility staff told him he was being discharged because he stole a computer and bullied other people to give him money and then, They brought me to [Charity name] and said I'm on my own. Resident #126 began to cry, and stated he had gotten rid of his tent, stove, and sleeping bag because, They said I could stay at the facility until I found a place. I've got no place to go, no sleeping bag and no phone. Resident #126 further stated, I'm probably going to get assaulted again and I hope someone gets me in the neck because I got no place to go.
During an interview on 9/13/23 at 3:50 p.m., staff member AA stated resident #126 had burned every bridge with regards to other placements. The facility reached out to [Facility name] and they stated they evicted him last time he was there and they declined accepting him back. Staff member AA stated resident #126 was fixated on where he was supposed to go, but he was homeless before he came here and it was approached that he was being discharged to his prior setting. The discharge team felt they needed to assist him in some way and the [Charity Name] gives him a place to light and buy him time. [Charity Name] does meals, breakfast, and lunch, I think. That seemed like a great plan .[Resident #126] was told, I think, (him coming to the facility) was a stop gap to get him off the street. Staff member AA further stated there was no official orders at the time of his discharge but that facility staff went over his belongings with him.
During an interview on 9/14/23 at 7:32 a.m., resident #11 stated resident #126 never threatened him and kept giving him candy. Resident #11 stated resident #126 made him nervous. Resident #11 stated he was never asked by staff if he wanted to move to another room, and he did not want resident #126 to be forced to move either.
During an interview on 9/14/23 at 8:20 a.m., staff member BB stated when the facility discharged a resident to home, the facility identified the resident was ready to go, and checked for support, family, etc. The facility made sure it was a safe discharge. Resident #126 was homeless when he was admitted at the facility. Staff member BB stated resident #126 was not following the rules of the facility, and his roommate, resident #11, feared him, and resident #11 was asked if he wanted to move into another room and he declined to move into another room. Resident #126 violated the rules by taking an iPad from therapy the first day he was at the facility, and was suspected of taking an iPad from a resident as well. Staff member BB further stated resident #126 told her he wanted to go to [Assisted Living Facility name] and his long-term goals were, Getting back on his own feet, and the facility tried to do that. Staff member BB said she was supposed to talk to [ALF staff name] or [ALF staff name] at [Assisted Living Facility name] that day. When questioned by this surveyor, Why did the facility wait to discharge him until she spoke with [Assisted Living Facility name staff] today and discharged him yesterday? Staff member BB stated, I didn't make the decision to discharge resident #126 yesterday.
During an interview on 9/14/23 at 8:51 a.m., staff member AA stated resident #126 did not agree with being discharged . Staff member AA further stated she did not think the reason for resident #126's discharge was breaking the rules, but, More of the safety of the other residents.
During an interview on 9/14/23 at 10:10 a.m., staff member A stated resident #126's discharge was a planned medical discharge, so he did not need to be offered an appeal.
A review of a social worker note, for resident #126, dated 9/12/23, showed:
SW met with [resident #126] to ask him what his plans are for [facility initials] LTC. Said he was told by [staff member W] about an ALF called [ALF name]. SW called The [ALF name] and found [ALF staff name] and [ALF staff name] are away the next 2 days on business and should return Thursday. [Resident #126] said he is hopeful to go to an ALF then get back out on his own.[sic]
A review of an email from staff member BB to staff member CC, dated 9/13/23, at 10:10 a.m., showed:
.UPDATE:
[Resident #126] shares a room with a male peer [resident #11]. [Resident #11] spoke with me about [resident #126] pacing all night long. [Resident #11] said this is upsetting to him and said it reminds him when his mentally ill father would pace their home at night. Said as a child his father would pace the house then enter his room and beat him with a belt while he slept. I asked this roommate about moving rooms and he said no and that he did not want [resident #126] to know he spoke with me.
We have talked with the MD that admitted [resident #126] and he is in agreement that if [resident #126] is breaking the rules we can DC him to homelessness .
A review of a facility document listing resident #126's diagnoses showed:
- Cirrhosis
- Esophageal Varices
- Hepatitis C
- Renal Mass
- Bipolar D/O
- Pancytopenia
- Liver Failure
- Substance Use D/O
- Nausea
- Chr(onic) Abdominal Pain
- Weakness
- Hx Kidney Carcinoma
- Unsteadiness on Feet
- Need for assistance with personal care.
A review of resident #126's care plan showed:
Social Services Care Plan,
Date, 9/5/23
.Discharge Planning: [Resident #126] would like to dc to an ALF on Medicaid waiver.
Goal,
[Resident #126] will be able to have LTC housing until transition to ALF housing.
Intervention,
- . SW/CTC will work with Pt to transition to next facility while awaiting Medicaid waiver placement in ALF (possibly [Facility name] 2nd floor)
- Honor decision-making and ensure that request/choice is safe.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure a resident had unnecessary medication removed from her orders at admission, and after not using for several weeks, for...
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Based on observation, interview, and record review, the facility failed to ensure a resident had unnecessary medication removed from her orders at admission, and after not using for several weeks, for 1 (#90) of 27 sampled residents. Findings include:
During an interview on 9/13/23 at 2:50 p.m., staff members EE and DD stated the facility providers did not typically write orders for Benadryl, especially not for help with sleep. Staff member DD looked up the Benadryl order for resident #90 and found it was started in acute care in the hospital, and did not find a rationale for continuing it after admission to the facility.
During an observation and interview on 9/14/23 at 8:18 a.m., staff member H stated, normally the facility providers would not order Benadryl for residents due to the risks, and the order may have been carried over from the hospital, in the assumption she had been taking it at home. Staff member H looked up resident #90's medication history on the computer. The history showed resident #90's Benadryl order since admission from the hospital, and it was administered from August 11-15, 2023, but none in the month since. Staff member H stated since the Benadryl was not used for several weeks, the orders should be discontinued soon, as pharmacy would automatically remove medications not used for a length of time.
Review of resident #90's current medication orders showed, diphenhydramine HCL [Benadryl] 25 - 50 mg PO QHS PRN, and PRN reason: Sleep, with a start date of 8/9/23 and still active.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility staff failed to properly administer a narcotic medication to 1 (#87) of 27 sampled residents, resulting in the resident receiving five times the dose...
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Based on interview and record review, the facility staff failed to properly administer a narcotic medication to 1 (#87) of 27 sampled residents, resulting in the resident receiving five times the dose ordered by the physician, a significant medication error, and creating the potential for significant harm. Findings include:
During an interview on 9/12/23 at 9:35 a.m., resident #87 stated something went wrong with her pain pump the night prior and she slept better than she had in years.
During an interview on 9/12/23 at 2:24 p.m., staff member E stated the pharmacy changed the concentration of the narcotic ordered for resident #87 and sent a new bag. The bag resident #87 was receiving had not run out by the end of staff member E's shift. Staff member E mentioned to the oncoming nurse resident #87 had received a new bag. When staff member F and staff member G started the new bag, they did not change the rate to account for the higher concentration, so resident #87 received a higher dose than she was supposed to. Staff member H found the error the next morning.
Review of the medication error report, dated 9/12/23, showed staff member E accepted the new bag containing a different concentration of medication, did not communicate clearly to staff member G the concentration had changed, and the pump would need to be reprogrammed, only that the volume had changed. The correct concentration of the narcotic was listed on the label of the bag. Staff members F and G hung the bag, but did not change the settings on the pump. The bag would not scan because it was a new order, and neither staff member called the pharmacy for clarification. Staff members F and G overrode the warning and documented the medication as an .unscheduled medication .
Review of the facility's policy titled, PCA Pump, GNC850, revised 3/2021, showed, The pump settings must be checked by two (2) RN's who will document on the PCA IV Flow Sheet upon initiation of therapy and following any medication or pump programming setting changes .
Review of a facility policy titled, Medications, AGN640, revised 7/2021, showed:
.C. Right Dose
1. Read dosage strength on medication label and compare with eMAR.
2. Check drug concentration .
.4. Verify any dose of which you are not certain .
8.Alert pharmacy of any non-scannable medications .
Review of a facility policy titled, Medications in Bar Coded Medication Administration (BCMA) Areas, BH219, revised 12/2021, showed:
. 9. Medications of any type will be administered after initially reconciling the medications with the medication administration record (MAR) and the Physician's order. The 6 rights of medication administration will be followed .
Dec 2022
1 deficiency
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Free from Abuse/Neglect
(Tag F0600)
A resident was harmed · This affected 1 resident
Based on interview and record review, the facility failed to keep a resident free from abuse, resulting in the resident feeling belittled and ashamed, for 1 (#49) of 3 sampled residents. Findings incl...
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Based on interview and record review, the facility failed to keep a resident free from abuse, resulting in the resident feeling belittled and ashamed, for 1 (#49) of 3 sampled residents. Findings include:
During an interview on 12/20/22 at 9:02 a.m., resident #49 stated she had an issue, back in October 2022, with NF1. Resident #49 stated one morning she woke up, and she was soaked with urine, after having an incontinence episode. Resident #49 stated NF1 was rude and curt with her, and told the resident, Anyone can feel when they have to go to the bathroom, why didn't you go last night? You are a grown woman. You are thoroughly disgusting, and you stink. I would rather have someone else to take care of today. Resident #49 stated this made her feel belittled and ashamed. Resident #49 stated she told the nurse on duty what had happened, and NF1 was taken off the resident's care right away. Resident #49 stated she currently felt safe at the facility.
During an interview on 12/20/22 at 2:54 p.m., staff member C stated since the incident between resident #49 and NF1 on 10/19/22, resident #49 had been sleeping more often, and had an uncharacteristic angry outburst towards staff member C when the staff member was trying to help the resident. Staff member C stated she had abuse training in the past year at the facility, and was aware that verbal abuse was a type of abuse.
During an interview on 12/20/22 at 3:06 p.m., staff member B stated NF1 was immediately let go, and other staff and residents were interviewed. Staff member B stated the nursing staff was also educated on interventions to approach and assist resident #49 with her incontinence.
During an interview on 12/20/22 at 3:14 p.m., staff member A stated abuse allegations were reviewed in QAPI, and during management huddles on Mondays and Fridays. Staff member A stated leadership ensured social work followed up with resident #49 after the incident in October with NF1. Staff member D stated resident #49 also had therapy sessions every week, and staff member D helped the resident process anything she needed to after the sessions.
Review of a facility reported incident, dated 10/19/22, showed NF1 was removed from the schedule, and an investigation was started after the event. The results of the investigation showed, .it was determined that unacceptable performance was displayed . requested [NF1] . contract to be ended immediately.
Review of an e-mail between the facility and contract staffing company, dated 12/20/22, showed NF1's termination date was 10/19/22.
Review of a facility document, Core Mandatory Part III Clinical Assessment, dated 8/29/22, showed NF1 passed an assessment for abuse training.
Review of a facility policy, Abuse: Definitions, Reporting, Education, and Prevention, BH106, dated 12/2021, showed:
1. Each resident has the right to be free from abuse, mistreatment, neglect . Residents must not be subjected to abuse by anyone, including but not limited to staff, .
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: 4 harm violation(s), $44,005 in fines. Review inspection reports carefully.
- • 32 deficiencies on record, including 4 serious (caused harm) violations. Ask about corrective actions taken.
- • $44,005 in fines. Higher than 94% of Montana facilities, suggesting repeated compliance issues.
- • Grade F (35/100). Below average facility with significant concerns.
Bottom line: Trust Score of 35/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Brendan House's CMS Rating?
CMS assigns BRENDAN HOUSE an overall rating of 3 out of 5 stars, which is considered average nationally. Within Montana, this rating places the facility higher than 99% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.
How is Brendan House Staffed?
CMS rates BRENDAN HOUSE's staffing level at 5 out of 5 stars, which is much above average compared to other nursing homes. Staff turnover is 47%, compared to the Montana average of 46%.
What Have Inspectors Found at Brendan House?
State health inspectors documented 32 deficiencies at BRENDAN HOUSE during 2022 to 2025. These included: 4 that caused actual resident harm and 28 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Brendan House?
BRENDAN HOUSE is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility operates independently rather than as part of a larger chain. With 110 certified beds and approximately 97 residents (about 88% occupancy), it is a mid-sized facility located in KALISPELL, Montana.
How Does Brendan House Compare to Other Montana Nursing Homes?
Compared to the 100 nursing homes in Montana, BRENDAN HOUSE's overall rating (3 stars) is above the state average of 3.0, staff turnover (47%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Brendan House?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is Brendan House Safe?
Based on CMS inspection data, BRENDAN HOUSE has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 3-star overall rating and ranks #1 of 100 nursing homes in Montana. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Brendan House Stick Around?
BRENDAN HOUSE has a staff turnover rate of 47%, which is about average for Montana nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Brendan House Ever Fined?
BRENDAN HOUSE has been fined $44,005 across 2 penalty actions. The Montana average is $33,519. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is Brendan House on Any Federal Watch List?
BRENDAN HOUSE is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.