cms_MT
Data source: Big Local News · About: big-local-datasette
5,734 rows
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| Link | rowid ▼ | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 1 | BENEFIS SENIOR SERVICES | 275012 | 2621 15TH AVE S | GREAT FALLS | MT | 59405 | 2017-03-09 | 226 | E | 0 | 1 | KTFZ11 | Based on observation, record review, and interview, the facility failed to protect residents during the investigation process for allegations of abuse for 6 (#s 8, 14, 26, 27, 28 and 32) of 36 sampled and supplemental residents. Findings include: Review of an incident report, dated 10/6/16, showed resident #8 sustained a 7 cms. reddish/brown bruise to her right wrist during an allegation of rough cares. The Plan to Prevent Further Abuse section did not show preventative steps taken by the facility to protect other residents from harm. The staff member identified in the allegation continued to work the floor with the residents through completion of her shift. Review of the facility's Abuse Policy and Procedure (prior to 3/9/17) did not show protective action was to be taken when a resident reported an allegation of abuse by a staff member. The policy and procedure failed to identify definitive steps for staff members involved in allegations of abuse. During an interview on 3/8/17 at 2:30 p.m., staff member S stated a procedure was followed when an allegation of abuse was voiced by a resident: -The social worker or nurse would be asked to talk to the resident. -Then the nurse manager would follow up and talk with the resident. -The nurse manager put in a 24-hour report to the state. -The nurse manager would interview all the staff members involved. -If needed, involved staff would be put on administrative leave. -The nurse manager would notify the Director of Nursing of the incident. -Education on abuse and resident rights would be repeated for all staff. Staff member S stated the CNA involved in resident #8's incident, self-reported to another staff member that the resident had complained of rough cares. During an observation on 3/9/17 at 8:06 a.m., staff member T brought an over-the-bed table into the dining room to be used by a resident, however the table did not fit under the resident's wheel chair. Staff member T pushed the table toward the dining room entrance. A female resident seated at a table close to the… | 2020-09-01 |
| 2 | 2 | BENEFIS SENIOR SERVICES | 275012 | 2621 15TH AVE S | GREAT FALLS | MT | 59405 | 2017-03-09 | 246 | E | 0 | 1 | KTFZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to furnish a table which accommodated the ability for 2 (#s 19 and 36) of 36 sampled and supplemental residents to feed themselves. The facility, at Westview, failed to accommodate wheel chair bound residents in 37 of 37 bathrooms, giving them the ability to see themselves in their bathroom mirrors. The facility failed to ensure 1 (#7) of 24 residents was accommodated with a bathroom doorway wide enough for entry. Findings include: 1. Review of resident #19's Quarterly MDS, with an ARD of 1/27/17, showed the resident was cognitively impaired and required assist with meals. During an observation on 3/6/17 at 4:35 p.m., resident #19 was observed in the Lodge dining room. The resident was seated in a smaller than usual Broda chair. The resident had poor head control and was bent forward, resting her hand on her chest. The resident's chair was pushed up to a table, farthest from the Lodge kitchenette. The table was level with resident #19's nose. The resident was drinking hot chocolate out of a plastic, lidded glass, with a straw. The resident had to reach up to the table to place her glass on the table top. The glass wobbled, tipped. The resident was unable to see up on the tabletop. During an interview on 3/6/17 at 4:35 p.m., resident #19 stated, Might would help if the table was lower, to eat by herself. During an observation on 3/7/17 at 4:43 p.m., resident #19 sat at the table farthest from the Lodge kitchenette. The resident was in a small broad chair. The table was at nose level. A plate with a half of a peanut butter/jelly sandwich was on the table in front of the resident. The resident tried to reach the sandwich. The resident was unable to grasp the sandwich. The resident was able to grab the plate, and pull the plate with the half sandwich to her lap. Staff member V placed the plate back on the table and cut a small piece out of the middle of the sandwich and encou… | 2020-09-01 |
| 3 | 3 | BENEFIS SENIOR SERVICES | 275012 | 2621 15TH AVE S | GREAT FALLS | MT | 59405 | 2017-03-09 | 280 | D | 0 | 1 | KTFZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to follow the established plan of care for swallowing precautions and assisting with protective boots for 2 (#s 15 and 19) of 24 sampled residents. Findings include: 1. Resident #15 was readmitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. During an observation on 3/6/17 at 12:33 p.m., resident #15 was on the other side of the dining room, eating at a table independently. The resident coughed periodically. Shortly after this observation, the resident was wheeled into his room. Review of the resident's meal tray card, found in a basket in the Goodnow kitchen, showed the resident was on a quality of life diet, required finely chopped meat approximately 1/8 to 1/4 inch size bites, required one small bite with swallow, and was to be encouraged to eat at a slow rate with dining room supervision. The resident required decreased distractions during the meals. During an observation on 3/7/17 at 12:35 p.m., staff member N rushed to resident #15 who was coughing and making gurgling sounds with a reddened face. Staff member N wheeled the resident into his room and held a spit cup under his mouth while he coughed. Staff member N stated he did not cough up anything. She brought him back to the dining room. She sat with him and offered him fruit chunks which were cut up approximately 2/3 of an inch in size. The resident drank his soda and coughed more. Staff member N only asked the resident to slow doww, no other instructions were provided to the resident. The resident was not told to alternate food bites with beverage sips or to swallow between each bite of food. When asked if the resident required supervision with meals, staff member N stated He eats alone. She stated she had some extra time right now to sit with the resident. She stated the staff were to remind him to slow down. The resident had small bites of roast beef with gravy and tater tots (not 1/8th or 1/4th qu… | 2020-09-01 |
| 4 | 4 | BENEFIS SENIOR SERVICES | 275012 | 2621 15TH AVE S | GREAT FALLS | MT | 59405 | 2017-03-09 | 312 | E | 0 | 1 | KTFZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to assist with bathing or showering for periods longer than seven days for 3 (#s 2, 3, and 20) of 24 sampled residents, and 1 (#19) of 24 sampled residents did not receive assistance with combing or brushing hair after lying down. Additionally, shower and bathing services in the Goodnow cottage lacked consistency and weekly frequency for at least 3 (#s 12, 30, 31) of 16 residents in this cottage. This deficient practice had the potential to affect all residents in the Goodnow cottage. Findings include: SHOWERS/BATHS 1. Review of resident #2's Significant Change MDS, with an ARD of 12/6/16, showed the resident's BIMS was 14, moderately intact, but she required extensive assistance with showering or bathing. Review of resident #2's Care Plan, with a start date of 1/3/17, did not address shower/bathing needs. During an interview on 3/9/17 at 9:32 a.m., resident #2 stated if she refused a shower, she would not receive another chance for a shower until the following week. The resident had to wait until the next week to receive a shower on her assigned shower day. Review of the electronic bathing reports for 12/16 - 3/8/16, showed resident #2 did not have a shower between the following dates: - 12/8/16 and 12/23/16, a span of 15 days, - 1/6/17 and 1/16/17, a span of 10 days. - 2/20/17 and 3/3/17, a span of 11 days. During an interview on 3/8/17 at 8:55 a.m., staff member V stated resident #2 went through periods of heavy sleeping and would refuse to take a shower. Staff should be offering a shower during the week. 2. Review of resident #20's Quarterly MDS, with an ARD of 2/28/17, showed the resident's BIMS at 9, moderately intact, and the resident required extensive assistance with showering or bathing. Review of resident #20's electronic bath reports, from 12/1/16 through 3/6/17, showed the resident did not have a shower between the following dates: - 12/17/16 and 1/1/16, a span of 13 days,… | 2020-09-01 |
| 5 | 5 | BENEFIS SENIOR SERVICES | 275012 | 2621 15TH AVE S | GREAT FALLS | MT | 59405 | 2017-03-09 | 371 | E | 0 | 1 | KTFZ11 | Based on observation, record review, and interview, the facility failed to prepare and serve food under sanitary conditions; failed to date foods when the foods were removed from their original containers; failed to ensure nursing staff wore aprons and contained their hair during food preparation and service in the kitchen (Goodnow); and failed to clean food contact or non-contact surfaces in the cottage kitchens. This deficient practice had the potential to affect all residents that received service from the kitchens in the cottages. The facility also failed to ensure food safety by allowing a freezer cooling unit to defrost and drip onto cases of food stored in the Westview kitchen walk-in freezer. This had the potential to affect all residents receiving food from the Westview kitchen. Findings include: 1. During an observation on 3/7/17 at 12:10 p.m., staff member F was washing dishes in the kitchen of the Goodnow cottage and staff member BB was setting food trays with silverware, tray cards and napkins. Neither of the staff members were wearing aprons. Both of the CNA's scrub tops (uniforms) were contacting the kitchen counters. At 12:15 p.m., staff member BB started to scoop soup into cups. She was not wearing a hair net or an apron. During this same observation, staff member F stated they pretty much did everything, in addition to their nursing tasks (bathing and toileting of residents), and dish washing, food preparation, kitchen inventory, food orders, and stocking the refrigerators. She stated homemakers also helped with dinner service and dish washing as needed. She stated they wore hair nets when they entered the culinary side of the kitchen only, when they were beyond the yellow line. At 12:55 p.m., staff member BB was wearing an apron and a hair net and was in the kitchen. Staff member C stated it was because staff member BB went behind the yellow line. Staff member BB stated she was preparing a grilled cheese sandwich for a resident. 2. During an observation on 3/7/17 at 5:10 p.m., staff members [NA… | 2020-09-01 |
| 6 | 6 | BENEFIS SENIOR SERVICES | 275012 | 2621 15TH AVE S | GREAT FALLS | MT | 59405 | 2017-03-09 | 411 | D | 0 | 1 | KTFZ11 | Based on record review, and interview, the facility failed to provide dental care for a resident who had a fractured tooth, for 1 (#5), and for a resident who had been referred for dental services, and who had mouth pain and discomfort, for 1 (#17) of 24 sampled residents. Findings include: 1. During a record review, the dental hygienist progress note for resident #5, dated 8/5/16, showed resident #5 had a missing crown with a fractured tooth. The hygienist documented that resident #5 needed to see a dentist. During an interview on 3/8/17 at 2:40 p.m., staff member S said staff member HH was the person who would schedule appointments with the dentist. During an interview on 3/8/17 at 3:30 p.m., staff member HH said she scheduled appointments with the dentist for residents, identified by the dental hygienist, who needed dental work done. Staff member HH said resident #5 saw the dental hygienist in (MONTH) of (YEAR), but she had not been scheduled to see a dentist. Staff member HH said the facility was having problems finding a dentist that would take residents with a medicaid pay source. Staff member S provided a copy of a document stating resident #5 was scheduled to see a dentist on 3/14/17, although this had not occurred prior to the survey. 2. During a record review of resident #17's Admission MDS, with an ARD of 2/28/17, section L, titled Oral/Dental Status, showed resident #17 had no natural teeth, and he had mouth or facial pain, discomfort or difficulty with chewing. The facility's dietician had noted the resident was to have chopped meat. During an observation on 3/8/17 at 12:30 p.m., resident #17 was eating spaghetti with meatballs. The meatballs had been cut into bite sized pieces. Resident #17 also had applesauce, and a piece of cake. The other residents seated at the table had spaghetti with meatballs, a garlic breadstick, and a piece of cake. During an interview on 3/8/17 at 12:30 p.m., resident #17's family member said the resident was eating applesauce instead of the garlic breadstick because He do… | 2020-09-01 |
| 7 | 7 | BENEFIS SENIOR SERVICES | 275012 | 2621 15TH AVE S | GREAT FALLS | MT | 59405 | 2017-03-09 | 441 | D | 0 | 1 | KTFZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure nebulizers were cleansed after each treatment and cleaned daily with soapy water for 1 (#14) of 24 sampled residents. This practice had the potential to promote the growth of bacteria and spread of infection to a resident receiving nebulizer treatments, and specifically for those receiving multiple treatments in a day. Findings include: Resident #14 was admitted to the facility on [DATE] with heart attack, [DIAGNOSES REDACTED], anxiety, depression, sacral pressure sore, chronic obstructive pulmonary disease, renal insufficiency, diabetes, and hypertension. a) Unbagged and uncovered nebulizer mask During an interview on 3/6/17 at 4:00 p.m., resident #14's nebulizer mask was placed on the bed side table. During an interview on 3/7/17 at 2:00 p.m., resident #14's nebulizer mask was placed on the bed side table next to the bed. During an interview on 3/7/17 at 3:02 p.m., resident #14's nebulizer mask was placed on the bed side table next to the bed. During this time, the resident was interviewed about bagging the nebulizer mask after treatments to prevent contamination. She stated no one told her to bag the mask, and no one bagged it for her. b) Rinsing of the nebulizer mask, pipe, and cup, after each treatment During an interview on 3/6/17 at 4:00 p.m., resident #14 stated she was independent with the administration of the nebulizer treatment as she also administered it at home. She stated the nurse set it up the treatments for her and left, and the resident turned it off at the end of the treatments. She stated no, they don't when asked if nursing came back within the 10 - 15 minutes of the treatment as it finalized and rinsed the device after each use. During an interview on 3/7/17 at 2:15 p.m., staff member C stated the residents use either the pipe or the mask, depending on their abilities. After the treatment, the resident turned off the machine and laid the ma… | 2020-09-01 |
| 8 | 8 | BENEFIS SENIOR SERVICES | 275012 | 2621 15TH AVE S | GREAT FALLS | MT | 59405 | 2017-03-09 | 456 | E | 0 | 1 | KTFZ11 | Based on observation, record review, and interview, the facility failed to ensure a system was in place for the identification, cleaning, and/or replacement of soiled oxygen concentrator filters for 3 of 4 sampled concentrators; and failed to follow the manufacturer's recommendations for the concentrators and filters used by the residents. This failure had the potential to affect any resident utilizing the concentrator equipment, and filters. Findings include: During observations of the facility on 3/7/17 at 2:35 p.m., oxygen concentrators were inspected in the residents' rooms. The exterior filters of the concentrators in resident rooms 501, 509, and 612 were found to have a heavy accumulations of dust build up. The dust also covered the panel under the filters. Review of the Perfecto2 Preventative Maintenance manufacturer's recommendations showed Remove the filter and clean at least once a week depending on environmental conditions. The recommendations further showed the explanation of the procedure for how to wash the filters and cautioned that the filters may need frequent cleaning. Additionally, the recommendations showed the concentrators were to be cleaned and disinfected between residents and explained what parts of the concentrator required disposal and replacement to prepare the machine for another resident's use. During an interview on 3/7/17 at 10:15 a.m., staff member C stated the concentrators received annual preventative maintenance, but she was not sure about the cleaning of the filters. She stated the concentrators were wiped down between residents, and once cleaned, placed in the storage room. The cleaning of the concentrator equipment was a shared task between the homemakers and the CNAs. On 3/7/17 at 2:14 p.m., staff member C also stated, upon further investigation, she found out that the concentrators received annual PMs (preventative maintenance) and the filters were replaced then. She stated as far as she knew, there was no system in place by nursing staff of monitoring the cleanliness of t… | 2020-09-01 |
| 9 | 9 | BENEFIS SENIOR SERVICES | 275012 | 2621 15TH AVE S | GREAT FALLS | MT | 59405 | 2018-05-17 | 554 | D | 0 | 1 | FGZ511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to ensure 1 (#45) of 37 sampled and supplemental residents had been assessed, and had physician orders, for the self-administration of medications prior to staff leaving medications at the bedside. Findings include: Resident #45 was admitted to the Memory Care Unit (MCU) with [DIAGNOSES REDACTED]. A review of resident #45's (MONTH) (YEAR) Medication Administration Record [REDACTED] 1. D-[MEDICATION NAME] 500 mg - take 2 capsules in or with 8-10 ounces of liquid by mouth three times daily. During an observation and interview on 5/17/18 at 12:13 p.m., staff member B entered resident #45's room with two medication capsules in a medication cup. The staff member exited resident #45's room, and asked another staff member to assist the resident from the toilet back to her room. The two capsules were left on an over-the-bed table, next to a plate of salad. At 12:33 p.m., staff member B stated she wasn't sure if resident #45 had a self-administration of medications assessment in the medical record. Staff member B stated she should not have left the capsules on the table without witnessing the resident take the capsules with 8-10 ounces of liquids as prescribed. Staff member B stated she had been orienting with another staff member, earlier in the week, but that staff member was on vacation. Staff member B stated she was the only staff member in the MCU passing medications that day, and she was still learning which resident was which. During an interview on 5/17/18 at 1:00 p.m., staff member C stated no residents on the MCU had a self-administration of medications assessment on file. Staff member C stated it was not safe to let the residents of the MCU self-administer medications without staff witnessing the administration. During an interview on 5/17/18 at 1:02 p.m., resident #45 stated she was not sure if she had taken the capsules that had been left on her table. The resident … | 2020-09-01 |
| 10 | 10 | BENEFIS SENIOR SERVICES | 275012 | 2621 15TH AVE S | GREAT FALLS | MT | 59405 | 2018-05-17 | 610 | G | 0 | 1 | FGZ511 | Based on interview and record review, the facility failed to thoroughly investigate an allegation of abuse, for 1 (#76) and prevent further abuse resulting in feelings of not being treated like a human, and fear of physical abuse, for 1 (#451) of 37 sampled and supplemental residents. Findings include: 1. During an interview on 5/15/18 at 2:40 p.m., resident #76 stated (staff member M) had been bird dogging me from the beginning of my stay here. A few weeks ago, (staff member M) said to me 'You keep that mask on or there will be trouble. I'll put you in your room, and you won't come out.' Resident #76 stated he did not need to wear the protective mask, and staff member M did not believe him. During an interview on 5/15/18 at 3:00 p.m., staff member N said she had been the nurse on duty that day, and she thought it was just a misunderstanding between the staff member and the resident. She said she told staff member M he needed to speak nicer to the residents. She thought the event had occurred on the 24th of (MONTH) (YEAR). During an interview on 5/16/18 at 1:36 p.m., NFI stated he was making rounds on 4/27/18, and he was visiting with resident #76. They sat in the lobby, and saw staff member M. Resident #76 and his wife became upset, and said staff member M was not supposed to be working in the cottage, because of their complaint against him. NF1 took the concern to the facility social worker, who stated he knew nothing about resident #76's concern. He discussed it with staff member L, who then did move staff member M to another area. Review of a communication note from staff member L, dated 4/29/18, showed she did talk to staff member M about the incident with resident #76. Staff member M stated the resident did become upset with him, because of the mask not being worn. Staff member M stated he was under the impression that the situation had been taken care of already. Staff member L wrote I assured staff member M he was not in trouble. Review of a written communication from staff member O, undated, showed, The … | 2020-09-01 |
| 11 | 11 | BENEFIS SENIOR SERVICES | 275012 | 2621 15TH AVE S | GREAT FALLS | MT | 59405 | 2018-05-17 | 656 | D | 0 | 1 | FGZ511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a care concern on the comprehensive care plan for the use of a [MEDICAL CONDITION] to assist the resident with the maintenance, addition of water, set up, and placing it on him, and the resident did not receive the ordered services for six months, for 1 (#40) out of 28 sampled residents. Findings include: Resident #40 was admitted to the facility with [DIAGNOSES REDACTED]. Review of resident #40's Annual MDS, with an ARD of 9/14/17, section G-Functional Status showed the resident required extensive assistance of two persons with bed mobility, transfers and dressing, and required extensive assistance of one person with hygiene and eating. Section O - Special Treatments, showed resident #40 required a respiratory treatment of [REDACTED]. During an observation and interview, on 5/14/18 at 1:20 p.m., resident #40 stated he used a [MEDICAL CONDITION] every night, and the staff did not help him. He stated he needed help to clean it, put water in it, set it up, and have staff place it on him. Resident #40 was limited in his ability to use his hands due to his [DIAGNOSES REDACTED]. The [MEDICAL CONDITION] was on his night stand next to his bed. During an observation and interview, on 5/15/18 at 3:10 p.m., resident #40 stated the last time he used the [MEDICAL CONDITION] was more than six months ago. Review of resident #40's Care Plan, with a start date of 3/15/18, failed to include a care area concern for resident #40's use of [MEDICAL CONDITION] for the [DIAGNOSES REDACTED]. During an interview on 5/17/18 at 2:31 p.m., staff member F stated the [MEDICAL CONDITION] was not on the resident's Care Plan or the TAR. Staff member F stated she obtained an order for [REDACTED]. | 2020-09-01 |
| 12 | 12 | BENEFIS SENIOR SERVICES | 275012 | 2621 15TH AVE S | GREAT FALLS | MT | 59405 | 2018-05-17 | 658 | D | 0 | 1 | FGZ511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility staff failed to meet professional standards of quality, by administering the wrong medication to the wrong resident, and failed to follow the 5 rights when administering medications to 2 (#s 19 and 35) of 37 sampled and supplemental residents. Findings include: During an observation and interview on 5/17/18 at 11:41 a.m., staff member B crushed a Tylenol 500 mg tablet at the medication cart for resident #19. Staff member B was observed looking at the MAR for resident #35. Resident #35's MAR indicated [REDACTED]. Staff member B stated resident #19 did not resemble the picture on the MAR indicated [REDACTED]. Staff member B stated, I know, (resident #19) used to look different as the staff member pointed to resident #35's picture. Staff member B walked away from the medication cart, and walked towards resident #19 with the crushed medication mixed in a tablespoon of ice cream. During an observation 5/17/18 at 11:43 a.m., staff member B administered the crushed Tylenol to resident #19. The resident stated she did not like the Tylenol with ice cream, and the resident made a grimacing face, and stated, It's not good. Staff member B stated, its ok, and continued spoon feeding resident #19 the crushed Tylenol. A review of resident #19's Annual MDS, with an ARD of 2/19/18, showed the resident had a BIMS of 9; moderate impairment. Her weight was 82 pounds. A review of resident #19's (MONTH) (YEAR) Medication Administration Record [REDACTED] a. [MEDICATION NAME] 650 mg suppository rectally every 4 hours if needed for fever or mild pain. b. [MEDICATION NAME] 325 mg take 2 tablets by mouth every 4 hours if needed for fever or mild pain. A review of resident #35's Annual MDS, with an ARD of 12/11/17, lacked a BIMS assessment. Her weight was 147 pounds. A review of resident #35's (MONTH) (YEAR) MAR indicated [REDACTED]. During an interview on 5/17/18 at 11:52 a.m., staff member K stated resident #… | 2020-09-01 |
| 13 | 13 | BENEFIS SENIOR SERVICES | 275012 | 2621 15TH AVE S | GREAT FALLS | MT | 59405 | 2018-05-17 | 689 | D | 0 | 1 | FGZ511 | Based on observation, interview, and record review, the facility failed to provide adequate supervision to keep a resident safe from six elopements and two falls (one with minor injuries), for 1 (#131) of 28 sampled residents. Findings include: Record Review of resident #131's Interdisciplinary Notes and Care Plan showed resident #131 eloped three times: a. 5/21/17 at 11:08 p.m., resident #131 left the doors from Eastview. Staff asked resident #131 to come back and stay on the unit. Resident #131 attempted to leave again out the unit doors by the nurse's station. Staff stopped him again. Resident #131 had clothing hidden under his coat. A review of the Care Plan showed, the intervention established was: resident #131 is monitored frequently by the staff. His room is checked frequently to see if he is in and if not to be sure of his where about's. In this case our monitoring and diligences prevented him from leaving the unit with clothing hidden under his coat. b. 6/4/17 at 2:00 p.m., resident #131 walked alone to the north tower information desk. The north tower staff called to alert the staff. Resident #131 was assisted back to the unit via wheelchair. Resident #131 was seen by the nurse in the dining room around 1:40 p.m. A review of the Care Plan showed, the intervention monitor frequently was established before this elopement. The new intervention method established was We have been told by the Clinical Engineering that the Wanderguard system is coming and then they will install it. We are not sure of the date. Until the system is installed, staff are doing half hourly checks in resident #131 when he is awake (sic). c. (no time or date) Resident #131 was found in the lobby during nightly rounds. During the walk back to his room resident #131 stated that he was going to leave tomorrow. He was escorted back to his room and the Eastview staff were notified.[NAME]remains on hourly checks, he had been checked and noted to be in his room several times before we were notified he was at the security station. A review… | 2020-09-01 |
| 14 | 14 | BENEFIS SENIOR SERVICES | 275012 | 2621 15TH AVE S | GREAT FALLS | MT | 59405 | 2018-05-17 | 695 | D | 0 | 1 | FGZ511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident was assisted with respiratory care needs for the use of and cleaning of a [MEDICAL CONDITION], and the resident did not receive the [MEDICAL CONDITION] treatments and services for six months, for 1 (#40) of 28 sampled residents. Findings include: Resident #40 was admitted to the facility with [DIAGNOSES REDACTED]. During an observation and interview on 5/14/18 at 1:20 p.m., resident #40 stated he used a [MEDICAL CONDITION] machine every night, and the staff did not help him. He stated he needed help to clean it, put water in it, set it up, and place it on him. Resident #40 was limited in his ability to use his hands due to his [DIAGNOSES REDACTED]. The [MEDICAL CONDITION] machine was on his night stand next to his bed. There were two one-gallon containers of distilled water under the night stand. Review resident #40's physician order, dated 9/25/17, showed [MEDICAL CONDITION]- use while sleeping, all sleeping. During an observation and interview on 5/15/18 at 3:10 p.m., resident #40 stated the last time he used the [MEDICAL CONDITION] machine was more than six months ago. The [MEDICAL CONDITION] machine was observed on his nightstand and was dry, with no water or condensation noted in the water tank, tubing or mask. The mask was laying on top of the [MEDICAL CONDITION] machine. The distilled water containers were observed to be in the same position under the night stand, with the same amount of water in them as observed on 5/14/18. During an observation and interview on 5/16/18 at 8:30 a.m., resident #40's [MEDICAL CONDITION] machine was next to his bed on the night stand. Resident #40 stated staff did not offer to help him with it last night. The [MEDICAL CONDITION] machine was observed to be dry with no water. The distilled water containers were observed to be in the same position, with the same amount of water in them, as observed on 5/15/18. Revie… | 2020-09-01 |
| 15 | 15 | BENEFIS SENIOR SERVICES | 275012 | 2621 15TH AVE S | GREAT FALLS | MT | 59405 | 2018-05-17 | 755 | E | 0 | 1 | FGZ511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to maintain a system that recorded, reconciled, and monitored the accountability and accuracy of dispensing [MEDICATION NAME], a narcotic medication, and failed to maintain accurate Medication Administration Record [REDACTED]. Findings include: During an observation and interview on 5/16/18 at 8:32 a.m., staff member C opened a locked cabinet in the medication room of the East View campus. Staff member C stated the Narcotic Lock Box, also known as an E-Kit, was kept inside the cabinet. The E-Kit was on the top shelf of the cabinet, and had a red plastic padlock seal. The numbers on the lock ended in 573. Staff member C stated the plastic padlock seal numbers should have ended in 525. Staff member C reviewed the E-Kit log, and stated the correct number for the new lock had not been recorded when the E-Kit was last inventoried. At 8:41 a.m., Staff members C and F discovered six doses of [MEDICATION NAME] were missing from the E-Kit. A review of the facility's E-Kit Record, dated 8/24/17 to 5/16/18, showed the last date staff had accessed the E-Kit was on 3/28/18, for an Inventory Check. During an interview on 5/16/18 at 8:52 a.m., staff member C stated staff should have verified the accuracy of the E-Kit by documenting the date, time, tag number when sealed (padlock seal), name of the item removed/added, along with two nursing signatures to ensure accuracy. Staff member C stated staff should have sent a facsimile to the pharmacist showing what had been removed/added. Staff member C stated the Narcotic Lock Box Record had a listing of information required when accessing the locked box. Staff member C stated she was not sure what happened to the [MEDICATION NAME], was not sure if the missing tablets had been administered to a resident, and to which resident the [MEDICATION NAME] had been administered to. During an interview on 5/16/18 at 12:21 p.m., staff member F stated sh… | 2020-09-01 |
| 16 | 16 | BENEFIS SENIOR SERVICES | 275012 | 2621 15TH AVE S | GREAT FALLS | MT | 59405 | 2018-05-17 | 761 | E | 0 | 1 | FGZ511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, several facility staff failed to ensure opened multi-dose vials of insulin, being administered to residents, were dated when opened, and not being used past the open-expiration date of 28 days, for 5 (#s 16, 36, 45, 56, and 77) of 37 sampled and supplemental residents; and failed to identify multi-dose vials were missing opened dates. Findings include: During an observation and interview on 5/16/18 at 9:10 a.m., review of the East View campus medication cart, showed opened, undated, multi-dose vials of insulin for residents #16, #36, #56, and #77 that were available for use. Staff member J stated staff were required to write an open date on multi-dose vials of insulin when opened. Staff member J stated if multi-dose vials of insulin have been opened, and were not dated, the vials should be discarded. Staff member J stated all staff members providing medications were responsible for checking the opened and the expiration dates for all medications administered by the staff. 1. a. Resident #16 was admitted to the facility with [DIAGNOSES REDACTED]. Review of resident #16's (MONTH) (YEAR) MAR indicated [REDACTED]. b. Resident #36 was admitted to the facility with [DIAGNOSES REDACTED]. Review of resident #36's (MONTH) (YEAR) MAR indicated [REDACTED]. c. Resident #56 was admitted to the facility with [DIAGNOSES REDACTED]. Review of resident #56's (MONTH) (YEAR) MAR indicated [REDACTED] - Humalog 100 units/ml- 10 ml vial with sliding scale instructions; and inject 2 units subcutaneous (SQ) 15 minutes prior to each meal. Hold if he is not going to eat a meal or if premeal (sic) capillary blood glucose (CBS) - [MEDICATION NAME] 100 units/ml- 10 ml vial; inject 10 units (SQ) every day at 8:00 a.m. d. Resident #77 was admitted to the facility with [DIAGNOSES REDACTED]. Review of resident #77's (MONTH) (YEAR) MAR indicated [REDACTED] - [MEDICATION NAME] 100 units/ml- 10 ml vial; inject 8 units SQ every … | 2020-09-01 |
| 17 | 17 | BENEFIS SENIOR SERVICES | 275012 | 2621 15TH AVE S | GREAT FALLS | MT | 59405 | 2018-05-17 | 812 | E | 0 | 1 | FGZ511 | Based on observation, interview, and record review, the facility failed to properly store dishes and equipment and failed to label and date foods in the main kitchen for the cottages. The findings had the potential to affect anyone who consumed food from the kitchen or food stored in the kitchen storage areas. Findings include: During an observation on 5/14/18 at 11:07 a.m. the following storage issues were observed in the cottage's main kitchen: a. The slicer was stored on a bottom rack under a table, next to the sink, uncovered, and next to Multi-quat sanitizer solution. During an interview on 5/14/18 at 11:22 a.m., staff member A stated the food slicer is usually stored on the shelf by the sink next to the multi-quat sanitizer solution, with a garbage bag covering it. b. Dishes were found spread out on a top shelf with no perforations to allow for the dishes to sanitarily dry; the dishes were uncovered, with water droplet stains on the dishes. c. Bowls and plates were found on the top shelf stored face up, and they were to be used as clean dishes in the future. d. Bowls were stored upright on a wire rack by the preparation table in a clear container that was uncovered and was dusty. This dishes had been cleaned prior, and were to be used as clean dishes in the future. e. Scoops and spoons were stored near the preparation table on a wire rack in clear containers, uncovered. There was a brown mixture splattered in the clear container that the scoops were touching. The clear containers were dirty with dust and food crumbs. During an interview on 5/16/18 at 10:56 a.m. staff member A stated that the clear containers holding the dishes, including the scoops, are cleaned weekly. Staff member A stated it looks like the one with the brown splatter needed to be cleaned. f. Plastic forks and knives were stored in the dry food storage room uncovered in a box, open to dust and debris. g. In the dry storage room there was a scoop left inside the closed kidney bean container with the handle of the scoop touching the kidney b… | 2020-09-01 |
| 18 | 18 | BENEFIS SENIOR SERVICES | 275012 | 2621 15TH AVE S | GREAT FALLS | MT | 59405 | 2019-07-11 | 554 | E | 0 | 1 | 01HJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to follow the self-administration of medication assessment, and maintain self-administration practices, for 3 (#s 47, 65, and 530) of 45 sampled and supplemental residents. Findings include: [NAME] During an observation and interview on 7/9/19 at 8:31 a.m., resident #47 was resting in his bed, with the head of the bed raised to 30 degrees. The lights in his room were off, and a plastic medicine cup filled with different medications was on his bedside table, which was placed parallel to resident #47's bed and within the resident's reach. No staff were observed in resident #47's room. Resident #47 stated, (Staff) must have left the cup of medications here .They usually do not let (medications) just sit like that. Resident #47 did not know when staff had brought the medication cup into his room and was unsure which medications he took in the mornings. Resident #47 did not know the name of the nurse in charge of his care that day. During an observation and interview on 7/9/19 at 8:38 a.m., staff member U entered resident #47's room to answer a call light. After assisting resident #47 with the urinal, she looked at the cup of medications, picked it up, and walked out of the room with the cup in hand. Staff member U stated if staff find medication cups with medications in the residents' rooms, they are to give them to the nurse. Staff member U then gave resident #47's medication cup to staff member B, who stated, Oh, I thought he took those. Review of resident #47's Self Administration of Medications form, dated 5/2/19, showed resident #47 requested he self-administer medications; however, upon assessment, it was determined resident #47 could neither safely self-administer medications, nor could he leave medications at the bedside. B. During an observation on 7/9/19 at 12:12 p.m., staff member H placed a medication cup with two unidentified tablets on the dining room table ne… | 2020-09-01 |
| 19 | 19 | BENEFIS SENIOR SERVICES | 275012 | 2621 15TH AVE S | GREAT FALLS | MT | 59405 | 2019-07-11 | 657 | D | 0 | 1 | 01HJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assess and update a resident's care plan for monitoring risks and interventions following a choking accident for 1 (#89) of 42 sampled residents. Findings include: During an observation on 7/8/19 at 4:50 p.m., resident #89 was eating alone in the back corner of the dining room. With a bedside table in front of him, a drink, and two bowls of pureed food. No staff were assisting or directly supervising to provide encouragement, or redirect the resident on alternating bites and sips, and to monitor for choking. During an observation and interview on 7/10/19 at 2:40 p.m., staff member L showed resident #89's diet card with 1:1 for dining. She stated the staff assisting meals may have missed the 1:1 for dining because the yellow post-it was covering the information. During an observation on 7/11/19 at 9:10 a.m., resident #89 was sitting alone eating breakfast in the back corner at the bedside table with three bowls of pureed food, and a drink for breakfast. No staff were assisting or providing 1:1 supervision to encourage alternating bites or sips, or to monitor for choking. Record review of resident #89's nursing note and an alert, dated 7/4/19, which showed resident #89 had a choking incident in which he turned blue and had to be given the [MEDICATION NAME] Maneuver. Record review of resident #89's Nutritional Status care plan, with a start date of 7/8/19, showed, Monitor for chewing and/or swallowing difficulties, . encourage small bites and sips alternated, .staff to assist if needed to eat. The 1:1 for dining was not on resident #89's care plan. Record review of resident #89's diet order card showed 1:1 for dining. Record review of resident #89's speech therapy notes, dated 7/8/19, showed precautions of 1:1 supervision. The skilled instruction category showed, ST discussed pt's recent choking episode with staff. Staff indicated pt. consumed a large bite of pureed solid… | 2020-09-01 |
| 20 | 20 | BENEFIS SENIOR SERVICES | 275012 | 2621 15TH AVE S | GREAT FALLS | MT | 59405 | 2019-07-11 | 686 | G | 0 | 1 | 01HJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to prevent and evaluate the cause of an avoidable, Unstageable pressure ulcer to the left heel, that led to the development of an additional Unstageable pressure ulcer to the right heel, and a reoccurring one to the left buttock, for a resident that was at high risk for pressure ulcers for 1(#1) of 42 sampled residents. Findings include: During an observation and interview on 7/8/19 at 1:54 p.m., resident #1 was sitting in her recliner with her heels resting on the bar to her side table. No interventions were noted to be place at the time for the prevention of pressure ulcers. Resident #1 stated her pressure wounds were from spending too much time in bed. During an interview on 7/10/19 at 2:29 p.m., staff member G stated the interventions for resident #1's pressure ulcers was heel lift boots, off loading heels, and a pillow to float heels. Staff member G stated resident #1 received [MEDICATION NAME] cream on her buttocks every shift and with toileting. Resident #1's heels were painted with [MEDICATION NAME] twice daily. During an observation on 7/11/19 at 10:07 a.m., resident #1 was sitting in her recliner, with both her heels resting on the floor, without a protective boot. Resident #1 was not sitting on a pressure relieving cushion in her recliner. During an observation and interview on 7/11/19 at 10:09 a.m., staff members G and I performed wound care with resident #1. Staff members treated resident #1's sacral wound, which staff member I stated was an Unstageable pressure ulcer, measuring 2.7 cm x 3.2 cm. Staff member I stated resident #1 tends to sit in her recliner often and should be using a pressure relieving seat cushion at all times. Staff member I then noted resident #1's seat cushion was in resident #1's wheelchair, not in her recliner. Staff members G and I were unable to explain how the pressure area had developed. Next, staff members G and I observed the wou… | 2020-09-01 |
| 21 | 21 | BENEFIS SENIOR SERVICES | 275012 | 2621 15TH AVE S | GREAT FALLS | MT | 59405 | 2019-07-11 | 689 | G | 0 | 1 | 01HJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide the necessary supervision and assistance needed for a resident who had swallow deficits and a choking episode, which required staff to provide the [MEDICATION NAME] Maneuver, for 1 (#89) of 42 sampled residents, and failed to implement interventions for ongoing risks related to choking. Findings include: During an observation on 7/8/19 at 4:50 p.m., in the resident dining room, resident #89 was left unattended in the back of the dining room, behind the serving table, in his wheelchair. Resident #89 was positioned behind a bedside table. Resident #89, with his tongue thrusting out, was coughing on his thickened water. No staff came to check on the resident. He then set his drink down on the bedside table to use his clothing protector to wipe his face and wheeled out of the dining room. A staff member wheeled resident #89 back into the dining room entrance and resident #89 proceeded to go to a different table and took his soiled clothing protector off and set it on another resident's place setting and drinks. Resident #89 returned to his bedside table where two bowls of pureed food and his drink were waiting. Resident #89 fed himself with an adaptive spoon, and due to his frequent tongue thrusting, he had to place the spoon far back in his mouth in order to empty the spoon. Resident #89 resorted to picking up the bowl and placing it against his lips to scoop the food with the adaptive spoon without taking a break, or switching to a drink in between bites of food. No staff were directly supervising or encouraging resident #89 to slow down or alternate food with liquids. Record review of resident #89's nursing note and alert, dated 7/4/19, showed, Res was in dining room sand resident chokking, he was unable to clear his airway and started turning blue. Res was lifted out of WC and [MEDICATION NAME] was started. After three deep thrusts I was able to dislodge te obj… | 2020-09-01 |
| 22 | 22 | BENEFIS SENIOR SERVICES | 275012 | 2621 15TH AVE S | GREAT FALLS | MT | 59405 | 2019-07-11 | 692 | D | 0 | 1 | 01HJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the dietary department failed to offer a carbohydrate controlled therapeutic diet ordered by a physician at meal times for 2 (#s 91 and 328) of 42 sampled residents. Findings include: 1. During an observation on 7/8/19 at 5:26 p.m., resident #91 received a full portion, filled to the brim of the bowl, of turkey and dumplings with peas and carrots. Resident #91 also received a salad, and a Diet Coke for dinner. During an interview on 7/8/19 at 5:28 p.m., staff member W stated a resident on a carbohydrate controlled diet should have been served no dessert, less potatoes, diet soda, and given less food or a half portion. During an interview on 7/9/19 at 1:54 p.m., staff member Y stated that all specialized diets should have been captured on the therapeutic spreadsheets that showed which food should be provided for the meal per the menu, as well as portion sizes. The sheets should have been used as a reference during meals. Carbohydrate controlled diets should have been provided unless the resident refuses. Staff member Y stated resident #91 should have received the baked turkey breast for dinner and not the turkey and dumplings. During an observation on 7/9/19 at 8:15 a.m., resident #91 received an omelet and muffin. Review of the Specialized Diet Spreadsheet for 7/9/19 showed a resident on a carbohydrate controlled diet should have received a Denver omelet, fresh fruit, yogurt, and cold cereal. Review of the Week 5 Monday Specialized Diet Spreadsheet, for 7/8/19, showed the carbohydrate controlled diet choices were pork chop smothered, creamy mushroom rice, and chocolate pudding, or baked turkey breast, peas, carrots, and onions. No baked turkey breast was observed during the meal. Review of resident #91's diet card showed, carb controlled diet was marked. The rest of the card was blank. Review of resident #91's diet order showed carbohydrate controlled diet. Review of resident #91's blood sug… | 2020-09-01 |
| 23 | 23 | BENEFIS SENIOR SERVICES | 275012 | 2621 15TH AVE S | GREAT FALLS | MT | 59405 | 2019-07-11 | 697 | G | 0 | 1 | 01HJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assess and provide pain management interventions during treatment of [REDACTED].#104) of 42 sampled residents, who described his pain as excruciating. Findings include: During an interview on 7/10/19 at 10:34 a.m., resident #104 stated he first noticed the pressure ulcer on his right heel prior to his arrival at the facility. Resident #104 explained the wound itself looked as if it were 90% healed, but .the bad part is the pain. Resident #104 described the pain on his right heel as excruciating, especially when staff performed dressing changes. Resident #104 stated he was unsure if he took pain medications prior to dressing changes on his right heel. During an interview on 7/10/19 at 10:51 a.m., staff member T stated resident #104, is fine, and has not needed or requested pain medications prior to dressing changes on his right heel. During an interview on 7/10/19 at 11:24 a.m., after staff member T was alerted to resident #104's pain, staff member T stated she would perform a dressing change on resident #104's right heel wound in about ten minutes. Staff member T stated, We ended up giving him a pain medication, so we are going to wait for that to kick-in. This was after the surveyor approached the topic of the resident's pain with the staff member. During an observation on 7/10/19 at 11:36 a.m., staff member T performed a dressing change on resident #104's right heel. While staff member T removed the compression stockings, resident #104 groaned in pain, and said Ow! multiple times. Staff member T did not perform a pain assessment, alter treatment, or implement pain relieving measures for resident #104 during the dressing change. During an interview on 7/10/19 at 2:37 p.m., staff member T stated she was not sure of the source of resident #104's pain. Staff member T stated resident #104 takes [MEDICATION NAME] as needed, but only requests it at night, and is not taking … | 2020-09-01 |
| 24 | 24 | BENEFIS SENIOR SERVICES | 275012 | 2621 15TH AVE S | GREAT FALLS | MT | 59405 | 2019-07-11 | 760 | D | 0 | 1 | 01HJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to administer [MEDICATION NAME] for pain at the dose prescribed, causing unrelieved pain for 1 (#7) of 42 sampled residents. Findings include: During an observation and interview on 7/8/19 at 3:20 p.m., resident #7 was folding resident covers for meals. The resident stated her arms and hands would become sore from the folding after awhile. Review of resident #7's physician's orders [REDACTED]. The order also showed the resident was able to have 1/2 tab three times daily as needed for breakthrough pain. During an observation and interview on 7/10/19 at 1:28 p.m., staff member A stated the nurses administering, per the Controlled Substance Medication Administration Record [REDACTED]. The count sheet showed that from 6/2/19 through 7/10/19, resident #7 did not receive the correct dosage of [MEDICATION NAME] on 6/12/19 at hs, 6/19/19 at hs, 6/24/19 at hs, 7/1/19 at hs, and 7/9/19 at hs. The resident did not receive any of her [MEDICATION NAME] doses on the evenings of 6/27/19 and 7/5/19. During an interview on 7/11/19 at 8:12 a.m., resident #7 stated she only took pain pills as prescribed, but that did not mean she did not have pain. The resident stated she had learned how to control her pain by putting it in the back of my mind. During an observation and interview on 7/11/19 at 10:10 a.m., staff member B showed how the [MEDICATION NAME] was packaged. One half pill of a 5 mg pill was in each blister pack. The staff member explained resident #7 received one blister pack for mornings and two blister packs for evenings. | 2020-09-01 |
| 25 | 25 | BENEFIS SENIOR SERVICES | 275012 | 2621 15TH AVE S | GREAT FALLS | MT | 59405 | 2019-07-11 | 761 | F | 0 | 1 | 01HJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure Schedule III-V controlled substances were separately locked, and not under the same access system used to obtain non-controlled substances; the facility failed to remove expired medication and supplies from medication supply rooms; and the facility failed to maintain staff education on checking expiration dates. Findings include: [NAME] During an observation and interview on 7/11/19 at 10:10 a.m., the medication refrigerator contained a ziplock bag of individually filled syringes containing [MEDICATION NAME] liquid for a resident and two medication cards containing dronabinol capsules for a resident. These medications are Schedule III controlled substances. The [MEDICATION NAME] and dronabinol were stored in the main area of the refrigerator and not locked separately from non-controlled medications. A locked box within the refrigerator contained a ziplock bag of individually filled syringes containing [MEDICATION NAME] liquid for stock use. Staff member L stated the stock items were locked as part of an e-kit. Staff member L stated she was not aware of the requirement for Scheduled controlled substances to be separately locked from non-controlled substances. B. During an observation and interview on 7/9/19 at 1:58 p.m., a bottle of aspirin 325 mg, which was located in the storage medication cart, had an expiration date of (MONTH) 2019. Staff member B stated, in reference to the facility's process for checking expired medications, the pharmacy goes through medication carts two to three times every month, and the night shift nurses are also pretty good at going through the carts to check for expired medications. During an observation of a medication storage room on 7/10/19 at 9:26 a.m., the following expired supplies were noted: -One Kangaroo E-pump Enplus spike set (exp. 1/14/19); -One E-pump safety screw spike set (exp. (MONTH) 2019); -One Prevantics Antiseptic … | 2020-09-01 |
| 26 | 26 | BENEFIS SENIOR SERVICES | 275012 | 2621 15TH AVE S | GREAT FALLS | MT | 59405 | 2019-07-11 | 812 | F | 1 | 1 | 01HJ11 | > Based on observation, interview, and record review, the facility failed to clean, maintain cleanliness, store food/equipment, or follow food services safety practices for the prevention of contamination of food or equipment uitlized, which had the potential to affect all residents recieving food in the facility. Findings include: During an observation on 7/8/19 at 1:18 p.m., Goodnow kitchenette had dried brown and yellow matter stuck to the range oven burners, whitish matter on the bottom of the fridge, and visible crumbs in the bottom of the warmer which had not been cleaned. During an observation of the Grandview main kitchen on 7/8/19 at 1:22 p.m., the convection oven had crumbs and black char on the bottom. The oven ranges had burnt food, dried leaves, and crumbs on the range oven tops. The ovens had splatters down the back of them, for the areas not previously cleaned. During an observation on 7/8/19 at 1:44 p.m., the Transitional Care Unit kitchenette stove top was visibly dirty with food splatters and burnt crumbs, with grease splattered on the back of range oven. Crumbs were found on the cookie sheets in the warmer, which was holding the clean plates, but the sheets had not been cleaned or removed from the day prior. During an observation on 7/9/19 at 7:47 a.m., the Transitional Care Unit kitchenette continued to have had dried food and yellow matter stuck to two of the four burners on the oven range top. Grease was splattered up the back of the stove. There were still crumbs on the cookie sheet, which was holding the clean plates in the warmer. During an observation on 7/10/19 at 9:26 a.m., the Transitional Care unit kitchenette had dried, cooked, and burnt food matter on the top of the stove, and crumbs on the cookie sheet, which the clean plates were sitting on in the warmer. During an interview and observation on 7/10/19 at 9:57 a.m., with staff member AA, while touring the Grandview main kitchen, there was a steam pipe from the steamer shooting steam out into the aisle-way of the kitchen. During th… | 2020-09-01 |
| 27 | 27 | BENEFIS SENIOR SERVICES | 275012 | 2621 15TH AVE S | GREAT FALLS | MT | 59405 | 2019-07-11 | 880 | E | 0 | 1 | 01HJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to label and ensure the safe storage of oxygen and nebulizer therapy supplies for 1 (#29); and a staff member failed to wear a mask during caring for residents while experiencing cold/flu type symptoms, and had a stated history of pneumonia, for 42 sampled residents, in an attempt to prevent the spread of infection. Findings include: 1. During an observation on 7/8/19 at 3:00 p.m., resident #29's used nebulizer canister setup was attached to, and setting on the top of, the nebulizer machine located on the resident's bedside nightstand. The canister contained droplets of liquid. The resident stated she had last used the nebulizer the previous afternoon (7/7/19), and that the nurses always set it up for her to use. A 7-2 label was written on the side of the nebulizer mouthpiece, canister ring lid, and oxygen tubing. An unopened package of ipatroprium [MEDICATION NAME] sulfate vials was laying on the bedside nightstand beside the nebulizer machine. During an interview on 7/11/19 at 10:05 a.m., staff member Q stated CNAs and nursing staff learn about nebulizer use during onboarding activities as a skills check off (competency), and nebulizer use was also presented last year during facility skills days. She stated that facility staff followed facility policies related to nebulizer use. During an observation on 7/11/19 at 10:09 a.m., resident #29's nebulizer canister and tubing set was attached to and setting on the top of the nebulizer machine located on the resident's bedside nightstand. The canister was dry and contained no liquid or droplets. An unopened package of ipatroprium [MEDICATION NAME] sulfate vials was laying on the bedside nightstand beside the nebulizer machine. During an observation and interview on 7/11/19 at 10:19 a.m., staff member R stated resident #29 had declined the nebulizer treatment earlier that morning and staff member R was preparing the nebulizer t… | 2020-09-01 |
| 28 | 28 | BELLA TERRA OF BILLINGS | 275020 | 1807 24TH ST W | BILLINGS | MT | 59102 | 2018-03-21 | 550 | E | 1 | 0 | U1E811 | > Based on interview and record review, the facility failed to ensure resident preferences were met for bathing for 5 (#s 5, 6, 8, 9, and 10) of 11 sampled residents. Findings include: 1. During an interview on 3/19/18 at 3:30 p.m., resident #5 said he was currently receiving two showers a week. Resident #5 said he wanted two showers a week, and he and NF1 had addressed that he had not consistently recieved two showers a week with the facility, repeatedly. Resident #5 said (MONTH) (YEAR) had been bad, and (MONTH) and (MONTH) of this year (2018) had been bad too (related to the provision of showers). Review of resident #5's Quarterly MDS, with an ARD of 12/5/17, showed the resident needed total assistance of two staff for bathing. During an interview on 3/20/18 at 3:35 p.m., NF1 said she and resident #5 had discussed his bathing preferences with the facility several times. NF1 said she thought residents were not getting bathed, based on their preferences, due to the facility not having shower aides available. Review of resident #5's Bath Aide Skin Assessment records, showed the resident had a bath on 9/11/17 and another one on 9/20/17. The resident went eight days without a bath. Review of resident #5's care plan failed to show the resident's bathing preferences, which was for a shower twice a week, had been identified by the interdisciplinary team. 2. During an interview on 3/21/18 at 7:45 a.m., resident #6 said she had gone nine days between showers. Resident #6 said she liked to have at least 2 showers per week due to her bowel incontinence. Resident #6 said she did not like to smell of body odor, feces or to have greasy hair, and she showered every day when she lived at home. Resident #6 said she would still like to have a shower every day but knew that was not possible. She had made the facility aware of her preference for two showers per week. Review of resident #6's Annual MDS, with an ARD of 1/2/18, showed the resident had not received a shower or bath in the seven day look back period. Review of resident … | 2020-09-01 |
| 29 | 29 | BELLA TERRA OF BILLINGS | 275020 | 1807 24TH ST W | BILLINGS | MT | 59102 | 2018-03-21 | 565 | E | 1 | 0 | U1E811 | > Based on interview and record review, the facility failed to provide evidence to show the facility take action to acknowledge and resolve, or attempt to resolve, all concerns brought forth by the resident council. This had the potential to affect all residents who attended the resident council or who had interest in the council's activities, and specifically 2 (#s 6 and 8), of 11 sampled residents. Findings include: During an interview on 3/21/18 at 8:30 a.m., resident #6 said shower/bathing concerns had been brought up repeatedly in resident council meetings. Resident #6 said she went around the facility before resident council meetings and talked to the residents. Resident #6 said the quality of the food and residents not getting showers were the biggest concerns. Resident #6 said the facility was aware of these concerns, but the facility had never responded to resident council concerns in writing. She said everything was verbally addressed. During an interview on 3/20/18 at 2:28 p.m., staff members A and I said they attended the resident council meetings. Staff member I said she was responsible for taking the minutes of the meeting and for the follow through on the concerns voiced in resident council. Staff member I said she was behind in her documentation in the software program. Staff member A said the facility had been treating resident council concerns as grievances since (MONTH) (YEAR). Staff member A said the grievance forms include, Action Item, Follow-up completed by, and Date of resolution. These grievance forms were not included with the resident council meeting minutes. Review of resident council meeting minutes showed; -10/2/17: A resident said her podiatrist was concerned residents were not getting their feet scrubbed properly during showers and the frequency of showers. No response from the facility. -11/6/17: A resident voiced concerns about showers. Another resident suggested a shower schedule be put in place. No response from the facility. -2/5/18: A resident had concerns about showers. No r… | 2020-09-01 |
| 30 | 30 | BELLA TERRA OF BILLINGS | 275020 | 1807 24TH ST W | BILLINGS | MT | 59102 | 2018-03-21 | 657 | E | 1 | 0 | U1E811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, observation and record review, the facility failed to update the care plan to accurately reflect the current status for 3 (#s 1, 5, and 6) of 11 sampled residents. Findings include: 1. During an interview and observation on 3/19/18 at 1:20 p.m., resident #1 stated she took care of herself, and did not need any assistance from the staff. The resident sat up in bed without assistance and sat at the edge of the bed to speak. During an observation on 3/20/18 at 11:05 p.m., resident #1 was walking without assistance or a device, to the nurses station. She stated she was going out to lunch that day. She was dressed up, had makeup on, and stated she had dyed her hair purple that morning. Review of resident #1's Care Plan, dated 7/28/17, showed the resident required guided maneuvering of extremities, verbal cueing and sufficient time to perform and/or assist during dressing and other ADL's as needed; transfer with walker and supervision; encourage resident to participate in ADL tasks as able. Review of resident #1's Care Plan, dated 7/28/17, showed she was at high nutritional risk. Review of resisdent #1's Weight sheet showed a severe weight loss of 13 percent from (MONTH) (YEAR) to her present weight of 95.6 pounds and was not identified on the care plan. Review of resident #1's discharge summary from the hospital, dated 1/2/18, showed the resident was diagnosed with [REDACTED]. The risk for dehydration with interventions and monitoring, was not addressed on the care plan. During an interview on 3/19/18 at at 1:30 p.m., resident #1 stated she smoked, and kept the cigarettes and lighter in her room, because the supplies kept disappearing. Review of resident #1's Care Plan showed she needed to check out smoking materials, and the supplies could not be kept in her room. During an interview on 3/20/18 at 1:20 p.m., staff member B stated she was not sure which staff member was to update resident care plans. Staff member B stated at … | 2020-09-01 |
| 31 | 31 | BELLA TERRA OF BILLINGS | 275020 | 1807 24TH ST W | BILLINGS | MT | 59102 | 2018-03-21 | 686 | G | 1 | 0 | U1E811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview, and observation, the facility failed to prevent the development of one unstageable pressure ulcer on the spine; and failed to have the supplies necessary for the physician-prescribed treatment order for a Stage IV pressure ulcer on the coccyx, for 1 (#2) of 11 sampled residents. Findings include: 1. Review of resident #2's At Risk report, dated 2/20/18, showed During rounds licensed nurse called writer to room of resident. Resident was lying on left lateral side. There were two red and blanchable skin spots on her posterior spine. There was one 1 X 1 unstageable on mid- [MEDICATION NAME]. The root cause was resident is very kyphotic and tends to lean against the back of the wheelchair, creating pressure points on back. Referral to therapy. Review of resident #2's physician order, dated 2/21/18, showed Skin prep wipes every morning and at bedtime for skin breakdown. And Resident to return to bed after each meal due to skin breakdown along spine, limited to one hour up maximum. Review of resident #2's Progress Note, dated 2/22/18, showed apply [MEDICATION NAME] dressings to spinal area and change every two days. During an observation on 3/20/18 at 1:20 p.m., resident #2 was up in her chair, after the 12 o'clock meal. There was no cushion to the back of her chair. At 2:30 p.m., resident #1 was still up in her chair. During an interview on 3/20/18, staff member [NAME] stated resident #2 did not like to return to her bed. Review of resident #2's Physician order, dated 3/9/18, showed PT to evaluate for back cushion in wheelchair 17 days after the pressure area and root cause were discovered. Review of resident #2's therapy evaluation for a back cushion for pressure relief, showed it did not occur until 3/20/18, during the survey investigation, and one month after the pressure ulcer was identified. Review of resident #2' Care Plan, dated 11/15/17, showed no identification of the spine pressure ulcer, or evidence … | 2020-09-01 |
| 32 | 32 | BELLA TERRA OF BILLINGS | 275020 | 1807 24TH ST W | BILLINGS | MT | 59102 | 2018-03-21 | 689 | G | 1 | 0 | U1E811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, observation, and record review, the facility failed to reduce multiple falls, one with a pelvis fracture, for 1 (#3); failed to monitor and modify interventions and failed to identify meaningful root causes for falls, for 2 (#s 3 and 11); and failed to ensure Hoyer lifts, used for transfers, were completed with sufficient staffing, for 1 (#5) of 11 sampled residents. Findings include: 1. Review of the facility Fall Report showed resident #11 fell 12 times from 10/25/17 through 3/16/18. On 12/14/17, she fell and fractured her pelvis. a. Review of resident #11's Follow-Up Report for the fall on 10/25/17, showed she fell out of her wheelchair. Her socks were slippery, and she landed on her bottom. The root cause was her non-skid socks were worn out and slippery. The recommendation for the prevention of future falls was for newer socks with a non-skid bottoms. During an observation on 3/20/18 at 10:00 a.m., resident #11 had regular socks on, and not non-skid socks. b. Review of resident #11's Follow-Up Report for the fall on 10/27/17, showed she slipped and fell on her buttocks, as she transferred herself from the wheelchair to the bed. The root cause was Pt. transferring herself said she slipped and fell . The recommendation was to lock wheelchair brakes and keep next to the bed. Automatic wheelchair brake to be installed by maintenance. Review of a second fall on 10/27/17, showed the wheelchair was not locked, and it rolled away and she fell on the floor. The facility failed to implement the locked brakes on the wheelchair. She was not wearing slipper socks. Review of the Maintenance Log, dated 10/30/17, showed Please put back up brakes on wheelchair. c. Review of resident #11's Follow-Up report for the fall on 10/28/17, showed she fell out of her wheelchair. The intervention for future fall prevention was, Dycem placed beneath and on top of her wheelchair cushion. During an observation on 3/20/18 at 10:01 a.m., resident #… | 2020-09-01 |
| 33 | 33 | BELLA TERRA OF BILLINGS | 275020 | 1807 24TH ST W | BILLINGS | MT | 59102 | 2019-04-18 | 644 | D | 0 | 1 | D2B811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to refer a resident with a newly evident or possible serious mental disorder or related condition for a Level II review, for 1 (#35) of 30 sampled residents. Findings include: Review of resident #35's provider progress note, dated 12/12/18, showed a [DIAGNOSES REDACTED]. Doing okay, will monitor . The provider progress note, dated 1/7/19, showed information that resident #35 was open to mental health care. Review of resident #35's provider order, dated 1/21/19, showed [MEDICATION NAME] 2.5 mg, was started, and it was to be given daily to the resident. The [MEDICATION NAME] was stopped on 2/27/19, due to the resident's development of tremors. Review of resident #35's provider order, dated 3/1/19, showed Quetiapine was started. Review of resident #35's MAR indicated [REDACTED]. During an interview on 4/18/19 at 8:14 a.m., staff member O stated he answered the questions on the MDS and would notify Social Services of a [DIAGNOSES REDACTED]. If it did happen, he would notify Social Services. A copy of resident #35's Level of Care Determination that included the newly evident [DIAGNOSES REDACTED]. No documention was provided prior to the conclusion of the survey. | 2020-09-01 |
| 34 | 34 | BELLA TERRA OF BILLINGS | 275020 | 1807 24TH ST W | BILLINGS | MT | 59102 | 2019-04-18 | 657 | D | 0 | 1 | D2B811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to update the comprehensive care plan for a resident with a severe weight loss, for 1 (#17) of 30 sampled residents. Findings include: During an observation on 4/16/19 at 6:23 p.m., resident #17 received pureed soup and ice cream for dinner, and the resident was not served the entire pureed meal, per the facility menu plan. Review of resident #17's Nutrition Care Plan, dated 4/11/18, showed she had the potential for alteration in nutrition. The care plan was not updated with a severe weight loss, and the plan did not specify the resident's dinner meal should be limited. Review of the nutrition goal showed, I will not lose greater than five percent (weight) and I will eat greater than 75%. All interventions, except for one, were dated 4/11/18. A new intervention, dated 11/15/18, was for a mechanical soft diet texture. A review of resident #17's physician orders [REDACTED]. The resident's weight loss had been occurring over the past year. During an interview on 4/17/19 at 8:20 a.m., staff member T stated she would update the resident's care plan with any new interventions. | 2020-09-01 |
| 35 | 35 | BELLA TERRA OF BILLINGS | 275020 | 1807 24TH ST W | BILLINGS | MT | 59102 | 2019-04-18 | 686 | D | 0 | 1 | D2B811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed nursing staff failed to thoroughly assess a pressure ulcer, and failed to obtain physician orders [REDACTED].#11) of 30 sampled residents. Findings include: During an observation on 4/16/19 at 11:15 a.m., resident #11 had an unstageable wound to the left heel. Review of resident #11's Admission/Readmission paperwork, dated 3/26/19, showed a pressure area to the left heel, which was unstageable, and the resident had been readmitted to the facility after a four day hospital stay. The wound measurements were not documented in the resident's paperwork. Review of resident #11's physician orders, dated 3/26/19, did not include wound treatment orders for the pressure area. During an interview on 4/17/19 at 12:40 p.m., staff member D stated she had been notified of resident #11's wound on 4/1/19, and removed the resident's Una Boots, which she believed contributed to the cause of the pressure injury to the resident's left heel. Review of resident #11's Wound Assessment Details Report, dated 4/1/19, showed the pressure area was 2.20 by 2.40 with 85 percent necrotic tissue. Review of resident #11's current treatment plan was [MEDICATION NAME] and 4x4 and wrap with gauze. The removal of the Una Boots was not documented on the plan. Review of resident #11's skin Care Plan showed it was not updated with the pressure injury until 4/15/19, over two weeks after the resident returned to the facility, although the treatment for [REDACTED]. It included off loading the resident's heel when in bed. During an interview on 4/17/19 at 1:00 p.m., staff member A stated it was typical for residents at the hospital to return to the facility without wound orders, but it was identified the facility failed to obtain the treatment order for the wound timely, to prevent worsening of the wound. | 2020-09-01 |
| 36 | 36 | BELLA TERRA OF BILLINGS | 275020 | 1807 24TH ST W | BILLINGS | MT | 59102 | 2019-04-18 | 689 | D | 0 | 1 | D2B811 | Based on observation, interview, and record review, the facility failed to provide food to a resident in the form ordered by the physician for safe swallowing for 1 (#17) of 30 sampled residents. Findings include: During an interview on 4/17/19 at 8:40 a.m., staff member T stated the CNA's should know when a resident is on a pureed diet, and provide pureed snack options. During an observation on 4/16/19 at 2:35 p.m., resident #17 was eating whole cookies, while sitting in her recliner. During an observation on 4/18/19 at 10:36 a.m., resident #17 had a package of cookies in her hand. Review of resident #17's diet prescription, dated 4/1/19, showed she was on a pureed diet. During an interview on 4/18/19 at 10:16 a.m., staff member I stated she knew the resident was on a pureed diet, and resident #17 should not have been provided cookies, because she could choke on them. | 2020-09-01 |
| 37 | 37 | BELLA TERRA OF BILLINGS | 275020 | 1807 24TH ST W | BILLINGS | MT | 59102 | 2019-04-18 | 692 | G | 0 | 1 | D2B811 | Based on observation, interview, and record review, the facility failed to provide a resident adequate assistance for eating; failed to assess the effectiveness of the weight loss and nutritional interventions and implement new interventions; and failed to provide a breakfast and lunch tray to a resident. The accumulation of the failures increased the risk of the resident's continued severe weight loss of 15 percent in six months, for 1 (#17) of 30 sampled residents. Findings include: During an observation on 4/16/19 at 9:09 a.m., resident #17 was sleeping in her reclining chair. No breakfast tray had been delivered to the resident. During an observation on 4/16/19 at 10:43 a.m., resident #17 had not appeared to have moved from her position, observed earlier that morning. During an observation on 4/16/19 at 12:20 p.m., resident #17 continued to appear to be in the same position from the morning observations. No lunch tray had been delivered to the resident. The resident responded to her name, smiled, and nodded 'yes' when asked if she was hungry. She was attempting to eat sugar free cookies. During an observation on 4/16/19 at 12:39 p.m., resident #17 was sleeping. An unwrapped Rice Krispee bar was on her bedside table. Review of resident #17's physician order, dated 4/1/19, showed she was on a pureed diet. During an observation on 4/16/19 at 1:43 p.m., staff member F entered resident #17's room and provided toileting care. No food or fluids were offered to the resident. During an observation and interview, on 4/16/19 at 6:23 p.m., resident #17 received a dinner tray consisting of pureed soup and ice cream. Staff member H stated the resident did not eat very much, but liked ice cream. During an interview on 4/17/19 at 8:40 a.m., staff member G stated she did not know why resident #17 did not get the pureed meal, as specified on the therapeutic breakdown sheet. She stated the resident room trays on resident #17's hall were delivered one at a time, by the CNAs, because the facility did not have a food delivery cart… | 2020-09-01 |
| 38 | 38 | BELLA TERRA OF BILLINGS | 275020 | 1807 24TH ST W | BILLINGS | MT | 59102 | 2019-04-18 | 755 | E | 0 | 1 | D2B811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure expired bottles of stock medications were removed from the medication carts and not readily available for resident use; and failed to ensure culture test swabs were not being used past their expiration date. This practice had the potential to affect all residents being administered stock medications or using supplies from the facility. Findings include: Expired Stock Bottles of Medications 1. During an observation and interview on [DATE] at 9:58 a.m., of the Rim View medication cart, with staff member C, a large bottle of Vitamin E, 1,000 unit capsules, was found in the stock supply. The expiration date printed on the bottle by the manufacturer read, ,[DATE]. Staff member C stated no residents were currently taking Vitamin E, but the medication should have been checked for an expiration date and removed from the cart. Staff member C stated medications in the medication carts were available for resident use. 2. During an observation and interview on [DATE] at 10:16 a.m., of the Mountain View medication cart, with staff member N, a large bottle of Magnesium, 400 milligram (mg) tablets, was found in the stock supply. The expiration date printed on the bottle by the manufacturer read, ,[DATE]. Staff member N stated she, Thought the unit manager checked for outdates. Staff member N stated she did not check for the expiration dates on stock medications she was dispensing because that was done by someone else. Expired Culture Swabs 3. During an observation and interview on [DATE] at 1:06 p.m., of the supply storage room on the 300 hall, with staff member S, two red-top and seven blue-top BBL Culture Swabs were found expired. The red-top swabs had an expiration date of [DATE], and the blue-top swabs had an expiration date of ,[DATE]. Staff member S stated all expired supplies should have been discarded and not available for resident use. A review of the facility's polic… | 2020-09-01 |
| 39 | 39 | BELLA TERRA OF BILLINGS | 275020 | 1807 24TH ST W | BILLINGS | MT | 59102 | 2019-04-18 | 761 | E | 0 | 1 | D2B811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to ensure opened multi-dose vials of insulin, being administered to residents, were dated when opened, and not being used past the open-expiration date of 28 days, for 3 (#s 17, 33, and 46) of 31 sampled and supplemental residents; and failed to ensure the storage of medications, including narcotics, found in the Emergency Kit (E-Kit) were properly secured on the 300 hall. Findings include: Insulin Pens without Open Dates 1. During an observation and interview on [DATE] at 10:14 a.m., of the Mountain View medication cart, with staff member N, three insulin pens for residents #17, #33, and #46, were found without an open date. Staff member N stated she did not administer insulin and therefore had no knowledge by whom, or when, the pens had been opened. During an interview on [DATE] at 10:50 a.m., staff member L stated she had opened and had administered insulin pens to residents #17, #33, and #46, earlier that morning. Staff member L stated she had forgotten to date each insulin pen, after opening, and had dispensed the unit dosages to the residents. Staff member L stated she should have ensured all insulin pens had been dated when opened. Staff member L proceeded to date each pen, [DATE], with a black marker. Staff member L stated the facility policy and procedure was to date when opened, multi-dose, insulin pens immediately after being opened and administered to the residents. a. Resident #17 was admitted to the facility with [DIAGNOSES REDACTED]. A review of resident #17's (MONTH) 2019 Medication Administration Record [REDACTED]. The start date was [DATE] at 6:00 a.m. b. Resident #33 was admitted to the facility with [DIAGNOSES REDACTED]. A review of resident #33's (MONTH) 2019 MAR indicated [REDACTED]. The start date was [DATE] at 8:00 a.m. c. Resident #46 was admitted to the facility with [DIAGNOSES REDACTED]. A review of resident #46's (MONTH) 2019 MAR indicated [R… | 2020-09-01 |
| 40 | 40 | BELLA TERRA OF BILLINGS | 275020 | 1807 24TH ST W | BILLINGS | MT | 59102 | 2019-04-18 | 883 | E | 0 | 1 | D2B811 | Based on interview and record review, the facility failed to determine whether residents had or had not received both PCV-13 and PSV-23 immunizations for 3 (#s 17, 21, and 28); failed to offer/provide PCV-13 for 2 (#s 17 and 28); and failed to provide PSV-23 for 1 (#21) of 30 sampled residents. Findings include: 1. Review of the immunization record for resident #17 showed PSV-23 was administered on 1/11/18. No documentation of refusal or administration of PCV-13 was found. 2. Review of the immunization record for resident #21 showed PCV-13 was administered on 1/10/18. Administration of PSV-23 was documented on 4/17/19, after the start of the survey. 3. Review of the immunization record for resident #28 showed PSV-23 was administered on 1/12/18. No documentation of refusal or administration of PCV-13 was found. During an interview on 4/18/19 at 7:59 a.m., staff member P stated the previous corporate owner did a house-wide pnuemonia vaccination in (MONTH) of (YEAR). Staff member P stated there needed to be a year between administration of the PCV-13 and the PSV-23. As PCV-13 was to be given first, the residents (#17 and #28) that recieved PSV-23 must have already received PCV-13. Staff member P stated, I guess I need to look into this to see if they (residents #17 and #28) actually received PCV-13. When asked, staff member P stated we (staff members A, P, and Q) talked this week about an audit to check the pneumonia vaccine status of all residents. | 2020-09-01 |
| 41 | 41 | BELLA TERRA OF BILLINGS | 275020 | 1807 24TH ST W | BILLINGS | MT | 59102 | 2018-06-14 | 554 | D | 0 | 1 | JJY911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents, who had medications in their room, stored them safely, and had physician orders [REDACTED].#s 3 and 61) of 19 sampled residents; and failed to assess 1 (#3) of 19 sampled residents for self-administration of medications. Findings include: 1. During an interview on 6/12/18 at 3:06 p.m., resident #3 stated she had been sick, with a bad cold, during the winter. She stated she was doing okay, as she had medications like cough drops, and a rub, that she could take by herself. She did not know where the medication was at the time, as she had moved from one room to another. Review of resident #3's Annual MDS, with an ARD of 12/12/17, showed the resident had a score of 14, very little to no cognition problems. Review of resident #3's Order Review Report, dated 4/1/18 - 4/30/18, showed the resident only had a medicated chest rub ointment, as needed for congestion, may have at bedside. The order date was 2/25/18. During an interview on 6/13/18 at 2:18 p.m., staff member B stated resident #3 did have a physician order [REDACTED].#3 to self-administer any medications. The staff member was unable to find the medications in resident #3's room. The staff member said the nursing staff were getting a discontinuation order of the medication. Review of resident #3's Care Plan, with a revision date of 5/31/18, did not show the resident was able to self-medicate any medication. Review of a Nurse/Provider Communication Form, dated 6/13/18, showed nursing staff had requested an order to discontinue the at the bedside order for resident #3's [MEDICATION NAME] cream, as the resident had not been using it for the past 30 days. There was no document showing the facility had put in a request to discontinue the chest rub or that the nursing staff were aware that resident #3 had cough drops. 2. During an observation and interview on 6/11/18 at 4:48 p.m., an opened bottle of Tums a… | 2020-09-01 |
| 42 | 42 | BELLA TERRA OF BILLINGS | 275020 | 1807 24TH ST W | BILLINGS | MT | 59102 | 2018-06-14 | 584 | D | 0 | 1 | JJY911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility staff failed to assist moving a resident into her room for 1 (#3) of 19 sampled residents, leaving the resident's room with boxes in the middle of the floor. Findings include: During an observation and interview on 6/11/18 at 2:55 p.m., two large boxes were sitting between resident #3's bed and her bedside table. Resident #3 stated she had been in the hospital. Prior to the hospital visit, the resident's roommate had bed bugs, and the resident had to move to another room. The infected room was sprayed for the bugs and her belongings were treated. The resident stated the social service person had moved her boxes down to her room but no one would help her put her belongings away. The resident stated the CNAs told her the task was not their job and they had too much to do. During an interview on 6/14/18 at 8:45 a.m., staff member S stated she had moved resident #3 back to her room. She had folded the resident's clothes and placed them in the dresser. The staff member stated she had not been back to resident #3's room and was unaware the resident still had unpacked boxes on the floor, in her room. The staff member stated she was unaware no staff had assisted resident #3 to finish unpacking. The staff member stated she had so much work, she could not follow up with resident #3's move. The staff member stated she had hoped the CNAs would have helped the resident with the remaining items. Review of resident #3's progress notes, dated 5/31/18, showed the resident was told she could move back to room [ROOM NUMBER]. The document showed staff could help with the move. | 2020-09-01 |
| 43 | 43 | BELLA TERRA OF BILLINGS | 275020 | 1807 24TH ST W | BILLINGS | MT | 59102 | 2018-06-14 | 657 | D | 0 | 1 | JJY911 | Based on observation, interview, and record review, the facility failed to ensure the care plan was updated to reflect the resident's current care needs and address fractured fingers on the resident's right hand, for 1 (#65) 19 sampled residents. Findings include: During an interview on 6/11/18 at 3:30 p.m. resident #65 stated she had fallen about a week or so ago while in the facility. She stated she broke two fingers on her right hand. During an observation on 6/11/18 at 3:30 p.m., resident #65 had an ace wrap around her right forearm, wrist, and fingers. Review of resident #65's care plan showed no information regarding the fractures fingers on the care plan. The care plan was dated 6/2/18. | 2020-09-01 |
| 44 | 44 | BELLA TERRA OF BILLINGS | 275020 | 1807 24TH ST W | BILLINGS | MT | 59102 | 2018-06-14 | 658 | D | 0 | 1 | JJY911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow professional standards of practice for counting narcotics at shift change to ensure the proper count for narcotics for 1 (#52); and failed to administer a medication as prescribed by a physician's orders [REDACTED]. Findings include: 1. During an observation on 6/13/18 at 1:45 p.m. staff member G was preparing medications for resident #52. A review of the resident's MAR indicated [REDACTED]. Staff member G took one pill out leaving seven pills. Staff member G opened the narcotic book to sign out the [MEDICATION NAME]. The book showed there were seven pills left and when staff member G took one out, there would then be six pills left. The last dose of [MEDICATION NAME] signed out was on 6/12/18 at 10:30 p.m. by staff member R. Staff member G looked at the pill she had taken out and stated the color of the pill was different than the color of the [MEDICATION NAME]. The [MEDICATION NAME] was dark purple in color and the pill taken out was light pink in color. [NAME] tape was observed taped on the back of the blister pack. Staff member G requested staff member C to come to the unit. Staff member G informed staff member C of the findings. During an interview on 6/13/18 at 1:45 p.m., staff member G stated she had counted the narcotics at shift change with staff member R. She stated staff member R looked at the book and she looked at the narcotic blister pack. She stated they would call out the page number for the medication while one nurse would look at the blister pack and the other nurse would look at the narcotic book during the count. During an interview on 6/13/18 at 2:25 p.m. staff member Q stated the nurses normally call the page number out, one nurse looks at the blister pack, and one nurse looks at the narcotic book. She stated neither of the nurses look at both the blister pack and the narcotic book when counting the narcotics. During an interview on 6/14/18… | 2020-09-01 |
| 45 | 45 | BELLA TERRA OF BILLINGS | 275020 | 1807 24TH ST W | BILLINGS | MT | 59102 | 2018-06-14 | 677 | D | 1 | 1 | JJY911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and interview, facility staff failed to answer call lights and respond to, or follow up on, resident care needs in a timely manner, for 3 (#s 3, 13, and 27), which caused #3 and #37 incontinent episodes, of 31 sampled and supplemental residents. Findings include: During an interview with the resident group on 6/12/18 at 1:56 p.m., residents stated the call light response time was terrible. They stated sometimes it would take up to one hour before someone would answer the call light. They stated, many times someone did not answer the call bell in time, and this would cause some resident's to be incontinent of bowel or bladder. The residents stated when that happened to them, it made them feel less than human or unclean. The resident group, consisting of 10 out of 10 residents, were unanimous in their feelings that the facility did not have enough staff to help all the residents with their care needs. During an interview on 6/11/18 at 2:55 p.m., resident #3 stated that when she used the toilet, she was often left in the bathroom for 45 minutes. The resident stated she was continent but had accidents (incontinent) if staff did not come for a lengthy amount of time. During an interview on 6/12/18 at 8:46 a.m., resident #27 stated that if staff did not assist in time, she had to go in her pants (incontinence). She stated she used the toilet and had no accidents if staff assisted timely. The resident stated she waited quite a while for staff to answer her call light. During an observation on 6/11/18, at 3:20 p.m., a call light went off in room [ROOM NUMBER]. room [ROOM NUMBER]'s call light was answered by staff at 3:47 p.m., after a span of 27 minutes. During an observation on 6/12/18 at 3:22 p.m., a call light was going off. Staff member M was overheard telling resident #13 that only two CNAs were on the hall. The staff member stated she was too busy to help answer call lights. During an interview on 6/12/18 at 3:30 p.m., st… | 2020-09-01 |
| 46 | 46 | BELLA TERRA OF BILLINGS | 275020 | 1807 24TH ST W | BILLINGS | MT | 59102 | 2018-06-14 | 684 | D | 0 | 1 | JJY911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility nursing staff failed to provide bowel regimen care for 1 (#66) of 19 sampled residents which resulted in significant discomfort for the resident. Findings include: During an interview on 6/12/18 at 9:05 a.m., resident #66 stated she had constipation problems, no regular bowel movements, and discomfort because of the constipation. Review of resident #66's Significant Change MDS, with an ARD of 5/21/18, showed the resident was cognitively intact. The MDS showed the resident was dependent on staff for toileting and required a two person assist. Review of resident #66's Care Plan, with a review completion date of 6/8/18, showed no documentation that the facility staff had identified a concern with the resident's constipation concerns. Review of the BM Report, for bowel movements, dated 3/22/18 through 6/13/18, showed resident #66 had no documentation of bowel movements from: - 3/22/18 until 3/31/18, nine days without a bowel movement documented, - 4/1/18 until 4/11/18, ten days without a bowel movement documented, - 4/12/18 until 4/20/18, eight days without a bowel movement documented, - 4/22/18 until 4/27/18, five days without a bowel movement documented, and - 4/28/18 until 5/8/18, ten days without a bowel movement documented. Review of resident #66's physician orders, dated 3/1/18 - 3/31/18, showed the resident had an order, with a start date of 3/6/18, for [MEDICATION NAME] solution, 10 grams, one time a day, every other day for constipation. Another order, with a start date of 3/6/18, showed the resident had a decrease in the amount given of [MEDICATION NAME] 10 g/15 ml syrup, give 30 ml every six hours as needed, to giving [MEDICATION NAME] 30 ml every 48 hours as needed. Review of physician orders, dated 4/1/18 - 4/30/18, showed resident #66 had an order for [REDACTED].>- Polyethylene [MEDICATION NAME], 17 grams powder, give by mouth one time a day for constipation. The order date was 1/22… | 2020-09-01 |
| 47 | 47 | BELLA TERRA OF BILLINGS | 275020 | 1807 24TH ST W | BILLINGS | MT | 59102 | 2018-06-14 | 692 | D | 0 | 1 | JJY911 | Based on observation and interview, the facility staff failed to provide water to residents in their rooms for hydration, for 2 (#s 39 and 61) of 19 sampled residents. Findings include: During an observation and interview on 6/13/18 at 2:29 p.m., resident #61 did not have water in his room. He stated staff did not pass water to the residents' rooms and said the staff told him they were too short staffed to pass the water. During an observation and interview on 6/11/18 at 2:14 p.m., resident #39 requested a drink of cold water. No water was available in the large water glass on the bedside table, next to her bed. During an interview on 6/12/18 at 4:00 p.m., staff member H stated all shifts should be passing water to residents' rooms. During the resident group interview on 6/12/18 at 1:56 p.m., the residents stated they did not feel there was enough staff. They stated many times they would not get water passed during the day, because the staff were too busy to complete the task. | 2020-09-01 |
| 48 | 48 | BELLA TERRA OF BILLINGS | 275020 | 1807 24TH ST W | BILLINGS | MT | 59102 | 2018-06-14 | 695 | D | 0 | 1 | JJY911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to have a policy to ensure regular cleaning of [MEDICAL CONDITION] equipment to prevent respiratory infection for 1 (#9) of 31 sampled and supplemental residents. Findings include: During an observation on 6/13/18 at 3:35 p.m., resident #9 was in her room. She had an oxygen concentrator and a [MEDICAL CONDITION] machine connected with tubing to a [MEDICAL CONDITION] mask at her bedside. None of the respiratory equipment was labeled for dates when it had been placed into use. During an interview on 6/13/18 at 3:35 p.m., resident #9 said she used her [MEDICAL CONDITION] machine every night for sleeping. She said she used it with humidification and pointed to a gallon jug of distilled water on her bedside table with approximately one cup of liquid left. The opened jug was not labeled with an open date. She said she would need more distilled water for the upcoming night. She said in the past she had to argue with staff to get distilled water because staff had told her it was okay to use water from the room sink, and she said she knew that was not safe. She said she had to ask staff to clean her [MEDICAL CONDITION] mask otherwise it would not get done. She said she liked to have it cleaned at least once a week. She did not remember what the manufacturer's instructions were as to how often her [MEDICAL CONDITION] equipment should be cleaned or when the last time her [MEDICAL CONDITION] machine had been checked. She said she did not know when the last time the connecting tubing to her [MEDICAL CONDITION] machine had been changed. A written request was made on 6/13/18 at 5:30 p.m. for the facility to provide a copy of the [MEDICAL CONDITION] policy. As of 6/14/18 at 10:00 a.m., a policy had not been provided. The facility did provide reference materials sent by the facility's respiratory equipment contract company that showed the [MEDICAL CONDITION] equipment manufacturer's instr… | 2020-09-01 |
| 49 | 49 | BELLA TERRA OF BILLINGS | 275020 | 1807 24TH ST W | BILLINGS | MT | 59102 | 2018-06-14 | 698 | D | 0 | 1 | JJY911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain and document vital signs when the resident returned to the facility after having [MEDICAL TREATMENT], failed to send medication to the [MEDICAL TREATMENT] clinic to be given as prescribed during [MEDICAL TREATMENT], and failed to plan individualized interventions for [MEDICAL TREATMENT] care for 1 (#s 48) of 3 sampled and supplemental residents on [MEDICAL TREATMENT]. Findings include: 1. During an interview on 6/13/18 at 8:50 a.m., staff member U said to prepare resident #48 for her scheduled [MEDICAL TREATMENT] treatment, she planned to get her FSBS and to administer her with sliding scale insulin if needed. She said she normally did not take the resident's vital signs and weight before sending the resident to the [MEDICAL TREATMENT] clinic. She said after residents returned from [MEDICAL TREATMENT], she usually checked their arteriovenous shunt sites for bleeding, and depending on how the resident looked, she might take the resident's vital signs. When shown a copy of the facility's [MEDICAL TREATMENT] Communication Record, staff member U said she had not previously seen the form and had never used it. A review of resident #48's TARS for (MONTH) and (MONTH) of (YEAR), did not show documentation of the resident's vital signs upon returning to the facility after [MEDICAL TREATMENT] treatments. A review of resident #48's Care Plan showed, Resident is at risk for End Stage [MEDICAL CONDITION] r/t Chronic Kidney Failure AEB weekly [MEDICAL TREATMENT]. Date Initiated 4/25/18. The interventions showed, Resident will be compliant with [MEDICAL TREATMENT] Appointments. The care plan did not mention the need for nursing assessments to include measurements of the resident's vital signs upon return to the facility, following [MEDICAL TREATMENT] treatment. 2. A review of resident #48's MARS for (MONTH) and (MONTH) (YEAR), showed the resident was ordered on [DATE] to receive [MEDICATION… | 2020-09-01 |
| 50 | 50 | BELLA TERRA OF BILLINGS | 275020 | 1807 24TH ST W | BILLINGS | MT | 59102 | 2018-06-14 | 755 | E | 1 | 1 | JJY911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, the facility failed to maintain an accurate Narcotic Log Record, which reflected the medications administration count of controlled medications for 3 (#s 7, 52, and 234) of 31 sampled and supplemental residents; the facility failed to maintain an accurate Controlled Substance Record which reflected the physician ordered medications for 1 (#59) of 31 sampled and supplemental residents; and failed to timely administer a controlled substance that had previously been signed out as administered for 1 resident (#50) of 19 sampled residents. Findings include: 1. Inaccurate Controlled Substance Record: a. During an observation on 6/13/18 at 1:58 p.m., staff member M reviewed the medications in the narcotic lock box of the Rehab One Medication Cart. A comparison of the Narcotic Log Book, page 30, with the medication card numbered 30, showed a discrepancy. The Narcotic Log Book showed resident #7's Sildenafil 20 mg tablets, had a count of 5 remaining. The medication card, numbered 30, for resident #7's Sildenafil 20 mg tablets, showed a count of 4 tablets remaining. Review of resident #7's EMAR showed one, Sildenafil 20 mg tablet, was administered to the resident on 6/13/18 at 11:00 a.m. During an interview on 6/13/18 at 2:17 p.m., staff member M stated she had prepared resident #7's Sildenafil tablet at 11:00 a.m., that day, not realizing the resident had left the facility. She stated she had already signed the medication as given on the EMAR at 11:00 a.m. She said she did not give the medication to the resident until around 2:00 p.m., when the resident returned to the facility. She stated the facility's expectation was not to sign out medication before they were given to the resident. She stated she must have forgot to sign the Sildenafil out of the Narcotic Log Book after she removed the pill from the blister pack in the narcotic lock box. She stated all controlled medications should be signed ou… | 2020-09-01 |
| 51 | 51 | BELLA TERRA OF BILLINGS | 275020 | 1807 24TH ST W | BILLINGS | MT | 59102 | 2018-06-14 | 759 | E | 1 | 1 | JJY911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, the facility failed to maintain a medication error rate of less than 5% in which three medications were omitted from the medication administration for 1 (#227), and failed to administer a medication in the dose and type prescribed, for 1 (#43), of 31 sampled and supplemental residents. The facility's medication error rate was 7%. Findings include: 1. During an observation on 6/12/18 at 7:40 a.m., staff member L prepared and administered the following medications for resident #227: - [MEDICATION NAME] 5 mg, one tablet, - Carvedilol 3.125 mg, one tablet, - [MEDICATION NAME] 20 mg, one tablet, - acidophilus, one tablet, - [MEDICATION NAME] Inhaler 250/50 mcg, one puff, - aspirin 81 mg, one tablet, - calcium 500 mg with Vitamin D, one tablet, - [MEDICATION NAME] and [MEDICATION NAME], two capsules, - magnesium 64 mg, one tablet, - Senna Plus, one tablet, - Thera-M, one tablet, - [MEDICATION NAME] 80 mg, one tablet, - cranberry 465 mg, one tablet. Review of resident #227's EMAR for (MONTH) (YEAR), and the Physician order [REDACTED]. - one losartan 50 mg tablet for hypertension, - one [MEDICATION NAME] 25 mg tablet for [MEDICAL CONDITION], and - one [MEDICATION NAME] 5 mg tablet for history of urinary [MEDICATION NAME]. During an interview on 6/13/18 at 11:34 a.m., staff member L stated she was not aware she had omitted the three medications from her medication pass for resident #227. She stated she reviewed the medications on the EMAR and then retrieved the medication card. She would then pop the medication out of the card, and return the card to the drawer. She stated the EMAR could be confusing, because there were medications which were ordered at different times so the EMAR would not turn yellow even if the medication was due at the same time as the other medication. She stated the medications were entered into the EMAR by the nurse manager, and sometimes different nurse managers order the m… | 2020-09-01 |
| 52 | 52 | BELLA TERRA OF BILLINGS | 275020 | 1807 24TH ST W | BILLINGS | MT | 59102 | 2016-12-15 | 221 | D | 0 | 1 | PSRD11 | Based on observation, record review, and interview, the facility failed to allow a resident the ability to move around freely while at meal service for one (#13) of 19 sampled residents. Findings include: During an observation in the Mountain View dining room, on 12/15/16 at 7:50 a.m., resident #13 was sitting at a table, with a meal in front of her. Resident #13 was in a wheel chair. The resident tried to leave the table. The resident could not leave. The resident's wheel chair just turned in a semi circle. The right brake was set. The resident's table mate asked if resident #13 could unlock the wheel chair brakes. Resident #13 looked down at the brakes and said no. The resident waited until a CNA released the brake and assisted her out of the dining room. Review of resident #13's Annual MDS, with an ARD of 9/13/16, showed the resident's BIMS at a 2, severe impairment. During an interview on 12/15/16 at 8:54 a.m., staff member A stated resident #13's wheel chair was not generally locked at the dining room table. The staff member was unaware the resident's wheel chair brakes were locked or who had locked the brakes. The staff member stated residents were not to have their wheel chair brakes locked by staff. | 2020-09-01 |
| 53 | 53 | BELLA TERRA OF BILLINGS | 275020 | 1807 24TH ST W | BILLINGS | MT | 59102 | 2016-12-15 | 225 | D | 0 | 1 | PSRD11 | Based on record review, observation, and interview, the facility failed to ensure an accusation of verbal abuse by one (#20) of 22 sampled and supplemental residents, was reported within the required timeline (within 24 hours) to the state agency. Findings include: During an observation in the Mountain View dining room on 12/12/16 at 12:19 p.m., resident #20 stated a staff member had yelled at resident #21, stating I'll get to it when I get to it before you die. Staff member C approached resident #20, asking what was wrong. Resident #20 told the staff member again what had happened. The staff member asked which staff member it was but the resident was unsure. During an interview, directly after resident #20 reported the allegation, staff member C stated the incident sounded strange, and she/he would look into the allegation to appease resident #20. The staff member stated resident #20 was not always correct in his reporting as he had dementia. During an interview on 12/15/16 at 8:04 a.m., staff member B stated if a confused resident described an alleged verbal abuse, she would report to the head nurse, the DON, or the administrator if needed. Review of resident #20's Quarterly MDS, with an ARD of 11/1/16, showed the resident had a BIMS of 5, severe cognitive impairment. During an interview on 12/14/16 at 8:49 a.m., staff member D stated she was not aware of resident #20's accusation of any staff verbal abuse. The staff member stated there was no information in the resident's medical records of the allegation of abuse. At 10:15 a.m. staff member D stated she would investigate. At 11:02 a.m., staff member D agreed the incident should have been reported by staff member C. Staff member D reported that staff member C said she didn't see the accusation as abuse. Staff member D stated she provided education to staff member C on reporting abuse. Review of the state agency event reports showed the facility had not reported the accusation of verbal abuse until 12/14/16, after being made aware of the allegation. | 2020-09-01 |
| 54 | 54 | BELLA TERRA OF BILLINGS | 275020 | 1807 24TH ST W | BILLINGS | MT | 59102 | 2016-12-15 | 241 | D | 0 | 1 | PSRD11 | Based on interviews, observations, and record review, the facility failed to provide a resident with a bath, and make a resident's bed as requested, for one (#7) of 19 sampled residents. Findings include: 1. During an interview on 12/13/16 at 8:35 a.m., resident #7 stated that she had only received a bath one time per week. She stated that she had asked for a bath more frequently but had not been allowed, and had not able to pick the time she wanted a bath. The resident stated she wanted a bath at least two times per week but had not been able to get one when she had asked the staff. Resident #7 stated she had felt stinky. The resident stated she had not refused any of her baths. During an observation on 12/13/16 at 8:35 a.m., resident #7 was sitting in her wheelchair in her room. The resident had a strong body odor present during an interview with a surveyor. During an interview on 12/13/16 at 9:00 a.m., staff member [NAME] stated resident #7 had refused her bath sometimes when she had already been dressed for the day. She stated staff utilized the Bath Aide Skin Assessments for the residents. A review of the facility's Bath Aide Skin Assessments showed that resident #7 had received only one bath in (MONTH) (YEAR), three baths in (MONTH) (YEAR), five baths in November, and three baths up until 12/13, in December. 2. A review of the facility's Resident Council Complaint Forms, showed residents had complained of beds being unmade on 4/4/16 and 11/7/16. During an interview on 12/13/16 at 8:35 a.m., resident #7 stated her bed had finally been made, that day. The resident also stated that she would like her bed to be made every day, but it had not been made every day. During an interview on 12/13/16 at 9:15 a.m., staff member F stated resident rooms should be cleaned daily, which would include making the bed. During an observation on 12/14/16 at 2:55 p.m., resident #7 had been sitting in her wheelchair, in her room. The bed had not been made, and the pillows were at the foot of the bed. Review of the facility's Daily… | 2020-09-01 |
| 55 | 55 | BELLA TERRA OF BILLINGS | 275020 | 1807 24TH ST W | BILLINGS | MT | 59102 | 2016-12-15 | 253 | E | 0 | 1 | PSRD11 | Based on observation, interview, and record review, the facility failed to consistently clean entry ways, floors, dining room tables, and window screens. The facility failed to consistently clean an electric wheel chair for one (#4); failed to thoroughly clean the resident room for one (#6); and failed to consistently clean a toilet for one (#7) of 19 sampled residents. Findings include: 1. During an observation on 12/13/16 at 11:10 a.m., resident #4 was in the Mountain View dining room. The resident was seated in an electric wheel chair. There was a right arm support connected to the wheel chair. Dried food, skin particles and a white colored stain, appearing to be the skin particles mixed with moisture from the resident's arm, were observed on the arm support, and beneath on the chair and right wheel. During an observation on 12/14/16 at 9:43 a.m., resident #4's wheel chair was against the outside wall of room 108. Dried food, skin particles, and the discolored white stain continued to be on the wheel chair arm support, on the chair, and the right wheel. During an observation on 12/14/16 at 2:21 p.m., resident #4 was assisted to bed. The resident's wheel chair was against the window in the room. Dried food and skin particles were on the wheel chair arm support, along with the discolored white stain. Skin particles and dried food were observed under the arm support, side of the chair, and wheel. During an observation on 12/14/16 at 4:25 p.m., resident #4 was in the Mountain View dining room. Skin particles and the white stain remained on the arm support of the wheelchair. Dried skin particles and dried food remained under the arm support, down the wheel chair wheel. Review of the Mountain View wheel chair washing schedule showed resident #4's wheel chair was to be washed on Tuesdays by night shift staff. During an interview on 12/13/16 at 3:30 p.m., staff member V stated that cleaning wheel chairs was up to the night shift. She stated she had observed some wheelchairs which looked like they had not been cleaned.… | 2020-09-01 |
| 56 | 56 | BELLA TERRA OF BILLINGS | 275020 | 1807 24TH ST W | BILLINGS | MT | 59102 | 2016-12-15 | 279 | E | 0 | 1 | PSRD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews, and observations, the facility failed to follow the care plan for a lactose free diet and offering an alternative meal if less than 50% of the original meal was consumed, for one (#1); failed to follow the care plan for straight cathing a resident three times a day, and for a specialized diet for one (#7); and failed to document restorative services on the care plan, and follow a restorative services plan, for a resident with contractures, for one (#10) out of 19 sampled residents. Findings include: 1. Care Plan for Catheter: Review of Resident #7's Physician order [REDACTED]. Review of Resident #7's Care Plan Report, with an effective date of 9/13/16 to present, showed that the resident's intervention was to straight cath, per MD orders, for [DIAGNOSES REDACTED]. Review of Resident #7's Treatment records and Clinical Notes for (MONTH) and (MONTH) (YEAR), showed inconsistencies in the resident being straight cathed three times daily as care planned. During an interview on 12/13/16 at 9:00 a.m., resident #7 stated she should be getting straight cathed three times daily. The resident also stated the staff had not been straight cathing her three times a day. During an interview on 12/13/16 at 3:25 p.m., resident #7 stated she had not been straight cathed yet today. The resident stated the nurse had not came back to cath her. During an interview on 12/13/16 at 3:30 p.m., staff member J stated resident #7 had straight cathed herself at home prior to being admitted to the facility. She also stated the resident had been scheduled to be straight cathed at 5 a.m., 2 p.m., and 10 p.m. Staff member J stated resident #7 had episodes of urinary tract infections. She also stated sometimes the resident had refused to be cathed. 2. Care Plan for Lactose Free Diet: Review of Resident #7's Physician order [REDACTED].>Review of Resident #7's Care Plan Report, with an effective date of 9/13/16 to present, showed the resident … | 2020-09-01 |
| 57 | 57 | BELLA TERRA OF BILLINGS | 275020 | 1807 24TH ST W | BILLINGS | MT | 59102 | 2016-12-15 | 312 | D | 0 | 1 | PSRD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide oral care to one (#3) of 19 sampled residents. Findings include: During an observation on 12/13/16 at 7:25 a.m., resident #3 entered the dining room. During visiting, the resident's mouth and teeth, which had a white colored mucous covering them, was observed. The resident's tongue was whitish in color. The resident reached into his mouth with his fingers and grabbed at the whitish mucus on his tongue and teeth, trying to get it out of his mouth. During an interview on 12/13/16 at 7:30 a.m., resident #3 stated his teeth had not been brushed, but they needed to be brushed. During an interview on 12/15/16 at 8:54 a.m., staff member A stated resident #3 needed assistance with set up and stand by assistance for brushing his teeth. Review of resident #3's Annual MDS, with an ARD of 7/19/16, showed the resident needed extensive assistance with personal hygiene. Review of resident #3's care plan, with a goal date of 1/17/16, showed the resident required assist of one with ADLs, including oral care related to forgetfulness, Alzheimer's, [DIAGNOSES REDACTED], and [MEDICAL CONDITION]. | 2020-09-01 |
| 58 | 58 | BELLA TERRA OF BILLINGS | 275020 | 1807 24TH ST W | BILLINGS | MT | 59102 | 2016-12-15 | 329 | E | 0 | 1 | PSRD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and observation, the facility failed to complete gradual dose reductions for residents on either antipsychotic or hypnotic medications for 3 (#s 1, 12, and 15) of 19 sampled residents. The findings include 1. Resident #1 had a psychiatric [DIAGNOSES REDACTED]. Review of resident #1's Medication Administration Record, dated (MONTH) (YEAR), showed resident #1 was receiving [MEDICATION NAME] 7.5 mg Tablet Oral, each day, starting 11/12/15. The orders showed to take the medication before dinner, at 1600, for [MEDICAL CONDITION]. She also had on order for 7.5 mg of [MEDICATION NAME], as needed every eight hours, starting 9/25/16, for acute agitation. Review of resident #1's medical record showed a lack of evidence for a gradual dose reduction for the [MEDICATION NAME] scheduled dose of 7.5 mg. During an interview on 12/13/16 at 3:03, staff member D stated resident #1's family did not allow the GDR's to be completed. She stated the resident's family member wanted the resident on the [MEDICATION NAME]. During an interview on 12/14/16 at 09:00 a.m., resident #1's family member stated they were unaware of what a GDR was, or why the facility should complete a GDR on medications. The family member stated they did not participate in the care plan meetings, so they were unaware if the facility had discussed a reduction of the scheduled dose of [MEDICATION NAME]. The family member stated that during the next appointment resident #1 had with the psychiatrist, they would ask about having the dose reviewed for the [MEDICATION NAME]. During an interview on 12/13/16 at 05:00 p.m., NFS 2 stated [MEDICATION NAME] was not ideal for the geriatric population. He stated he wrote to the psychiatrist asking for a GDR to be completed on the scheduled dose of [MEDICATION NAME], but he did not receive a response from the psychiatrist. He stated he also asked for a more definitive [DIAGNOSES REDACTED]. He also stated that he sent a letter… | 2020-09-01 |
| 59 | 59 | BELLA TERRA OF BILLINGS | 275020 | 1807 24TH ST W | BILLINGS | MT | 59102 | 2016-12-15 | 333 | D | 0 | 1 | PSRD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure staff primed the prefilled insulin pen prior to the medication administration for 2 (#s 12 and 22) of 22 sampled and supplemental residents. Findings include: Resident #12 was admitted to the facility with a [DIAGNOSES REDACTED]. Resident #22 was admitted to the facility with a [DIAGNOSES REDACTED]. During an observation on 12/12/16 at 4:30 p.m., staff member L put the needle on resident #12's [MEDICATION NAME] pen. The staff member twisted the dial back on the [MEDICATION NAME] pen to show 2 units of insulin. He then administered the insulin to the resident in the subcutaneous tissue in the left upper tricep. Staff member L did not prime the [MEDICATION NAME] pen with the 2 units of insulin prior to the insulin administration. During an observation on 12/12/16 at 5:01 p.m., staff member L, after placing the needle, twisted the dial back on the [MEDICATION NAME] pen to show 3 units of insulin. The staff member administered the insulin to the resident in the subcutaneous tissue of the right upper tricep. Staff member L did not prime the [MEDICATION NAME] pen with 2 units of insulin prior of the medication administration. During an interview on 12/12/16 at 5:03 p.m., staff member L stated he was not aware of the need to prime the insulin pen prior to the administration of medication. The staff member stated he had never primed the insulin pens before and had not been trained otherwise. During an interview on 12/12/16 at 5:15 p.m., staff member D stated it was the expectation of the staff to prime the insulin pen with 2 units of insulin prior administration. The staff member stated the last education provided to staff on the priming the insulin pens was at the last annual training. A review of the facility's Insulin Pen Instructions, dated 2/10/16, showed, Please use the following instructions prior to administering insulin from a prefilled pen: 2. You must give an… | 2020-09-01 |
| 60 | 60 | BELLA TERRA OF BILLINGS | 275020 | 1807 24TH ST W | BILLINGS | MT | 59102 | 2016-12-15 | 367 | E | 0 | 1 | PSRD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to follow the therapeutic diet that was ordered by a physician for 2 (#s 1 and 7), and failed to follow the physician ordered diet when providing snacks for one (#8) out of 19 sampled residents. Findings include: 1. Review of resident #1's diet order sheets, dated 5/6/16 and 6/30/16, showed the resident was to get both mechanical soft and pureed options at meal times. A physician's orders [REDACTED]. During an observation on 12/13/16 at 7:28 a.m., resident #1 was sitting in the Mountain View dining room waiting for her breakfast. She was served scrambled eggs and hot cereal. Staff left her sitting at the feeding assist table for a period of time after she appeared to be done eating. The resident consumed less than 10% of her meal. The staff members failed to offer her pureed eggs as a substitute, as the doctor's order showed. During an observation on 12/13/16 at 11:46 a.m., resident #1 was sitting in the Mountain View dining room, waiting for her lunch. Staff served her pureed carrots and mashed potatoes with gravy. The facility failed to offer her the mechanical soft diet prior to serving her the pureed carrots. During an interview on 12/13/16 at 12:00 p.m., staff member Z was asked why resident #1 received a pureed diet without getting mechanical soft textured food first. The staff member stated the resident had been receiving pureed meals. When the staff member was asked about the breakfast meal, and was reminded that the resident was only given mechanical soft food, the staff member recognized the resident was only given one option for breakfast. The staff member explained the resident's diet card showed the resident was to receive a pureed diet. Review of the resident's diet card for 12/13/16, showed the following orders: - may need assistance - dysphagia level 3 (advanced) and dysphagia level 1 (pureed) The diet card failed to specify instructions for which diet to … | 2020-09-01 |
| 61 | 61 | BELLA TERRA OF BILLINGS | 275020 | 1807 24TH ST W | BILLINGS | MT | 59102 | 2016-12-15 | 425 | D | 0 | 1 | PSRD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interviews the facility failed to ensure accurate dispensing and administration of a medication to one resident (#7) of 19 sampled residents. Findings include: Review of resident #7's (MONTH) (YEAR) MAR, showed the resident was allergic to sulfa (Sulfonamide Antibiotics). The resident had received a medication, Bactrim DS, 800 mg, on (MONTH) 1, (YEAR), to be given at the a.m. medication pass. Bactrim DS was a medication that contained sulfa. During an interview on 12/14/16 at 9:30 a.m., staff member K stated that to determine what medications a resident would be allergic to, she would have looked on the residents MAR. She stated she would have asked the resident what allergies [REDACTED]. She also stated that if a resident had received a medication they had an allergy to, the pharmacy should have been notified. A resident assessment should have been completed, including vital signs, and an incident report or risk watch form, should have been completed. During an interview on 12/13/16 at 5:00 p.m., staff member NF2 stated the pharmacy had original admission orders [REDACTED]. He stated it was a pharmacy medication error that resident #7 had been given a medication she was allergic to. He also stated he was not sure how the medication containing sulfa slipped through the cracks. During an interview on 12/14/16 at 5:00 p.m., staff member D stated a risk watch form was an internal facility investigation tool. She also stated resident #7 had told the nurse she was allergic to Bactrim after she had already been given the medication. Staff member D stated there had not been a risk watch form, or an incident report filed for the medication administration error. She also stated she was not sure how the error slipped through the physician and the pharmacy. Review of the facility's Resident Accident Incident Policy, dated 2/10/16, showed that upon identification of an incident, the information should be documented on an incid… | 2020-09-01 |
| 62 | 62 | BELLA TERRA OF BILLINGS | 275020 | 1807 24TH ST W | BILLINGS | MT | 59102 | 2016-12-15 | 441 | E | 0 | 1 | PSRD11 | Based on observation, interview, and record review, the facility failed to utilize standard precautions to prevent the spread of infections by failing to disinfect a glucose monitor between uses to prevent indirect transmission for 2 (#s 12 and 22); and staff failed to wear gloves during a glucometer check for 1 (#22) of 22 sampled and supplemental residents. These deficient practices had the potential to affect all residents receiving glucometer monitoring and testing. Findings include: 1. During an observation on 12/12/16 at 4:40 p.m., staff member L checked resident #12's blood sugar with the Even Care glucometer. Staff member L returned to his medication cart and removed the used test strip and placed the strip in the sharps container. Staff member L placed the glucometer down on top of the medication cart. The staff member did not clean the glucometer with disinfecting wipes after checking resident #12's blood sugar. During an observation on 12/12/16 at 4:50 p.m., staff member L checked resident #22's blood sugar with the same, soiled, Even Care Glucometer, which was used to check resident #12's blood sugar. Staff member L returned to his medication cart after checking resident #22's blood sugar, removed the soiled test strip, and placed the test strip in the sharps container. Staff member L placed the glucometer on top of his medication cart. He did not disinfect the glucometer after checking resident #22's blood sugar. During an interview on 12/12/16 at 5:00 p.m., staff member L stated he was aware he needed to wash the glucometer between resident uses. The staff member stated he should use the disinfecting wipes with the purple top between each resident use. Staff member L stated he forgot due to being nervous. Staff member L stated he received his last training on the maintenance of the glucometers about one year ago. During an interview on 12/12/16 at 5:15 p.m., staff member D stated it was the expectation of all nurses and certified medication aides to wipe the glucometers with the purple top disinfect… | 2020-09-01 |
| 63 | 63 | VALLE VISTA MANOR | 275021 | 402 SUMMIT AVE | LEWISTOWN | MT | 59457 | 2020-01-28 | 684 | G | 1 | 0 | 65C211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to monitor a resident for change of condition and follow through to obtain physician consultation, which resulted in a delay in treatment and ultimately a hospitalization , for 1 (#1) of 5 sampled residents. Findings include: During an interview on 1/28/20 at 12:24 p.m., NF1 stated he had noticed a difference in resident #1's cognition and status the two days prior to the hospitalization . NF1 stated he was in to see resident #1 on Saturday, 1/4/20, around one or two in the afternoon. NF1 stated he noticed a puddle on the floor around resident #1's foot and thought it was urine. He notified the nurse, and the nurse took resident #1's sock off, and NF1 immediately noted resident #1's foot was swollen like a balloon, and the fluid matter on the floor was not urine but was coming from resident #1's foot. NF1 stated he asked the nurse if he should take resident #1 to the hospital. The nurse stated no we have a wound nurse consult scheduled for Monday (six days later). NF1 stated it should have been obvious resident #1's foot was infected. NF1 stated he had not been notified of the swelling on resident #1's foot prior to seeing it in person. NF1 stated he received a phone call around 4:30 a.m., on Sunday 1/5/20, notifying him resident #1 was being sent to the emergency room . NF1 stated resident #1 was septic (infection) by the time he was admitted to the hospital, and the resident had [MEDICAL CONDITION]. During an interview on 1/28/20 at 1:27 p.m., staff member B stated she was not present in the facility when resident #1 had been sent out to the hospital. During the weekend it was the Registered Nurse that was in charge of overseeing cares. Staff member B stated the facility had been aware of the redness and swelling of resident #1's foot on 1/3/20. On 1/4/20 it was assessed, but resident #1 did not have a temperature until 1/5/20. Staff member B stated it would be alarming if a reside… | 2020-09-01 |
| 64 | 64 | VALLE VISTA MANOR | 275021 | 402 SUMMIT AVE | LEWISTOWN | MT | 59457 | 2020-01-28 | 686 | D | 1 | 0 | 65C211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to monitor an identified reddened skin area, and implement interventions for prevention of further deterioration, for the skin area, and the area worsened to an avoidable Stage II Pressure Ulcer; and the facility failed to identify the risk of the pressure ulcer development and revise interventions for a resident with a reoccurring pressure ulcer, for 2 (#s 1 and 2) of 5 sampled residents. Findings include: 1. During an interview on 1/28/20 at 12:24 p.m., NFI stated resident #1 had a red spot on admission that was not open. NF1 stated resident #1 was not repositioned, and the pressure ulcer worsened at the facility to the point resident #1 was uncomfortable when sitting. NF1 stated he was not sure if resident #1 moved nearly enough. NF1 stated he was aware of an order from the doctor for the pressure ulcer but was not sure if it had been adhered to. During an interview on 1/28/20 at 1:27 p.m., staff member B stated she was not in the facility for resident #1's admission, and she was not sure how resident #1 acquired the avoidable Stage II pressure ulcer. Staff member B stated the facility has not had many pressure ulcers and had recently implemented a system of caring for pressure ulcers. Staff member B stated the system included that a nurse would complete a skin assessment weekly, on a bath day, for a resident. Staff member B stated the implementation of the system was evaluated and is an ongoing process. Staff member B stated the resident had a head to toe evaluation in his progress note, after the abundant number of falls the resident had, during his stay at the facility. Staff member B stated resident #1 had Braden Scale skin assessments completed on the 19th, and the 26th of December, 2019, as well as on January 2nd, of 2020. During an interview on 1/28/20 at 2:46 p.m., staff member A stated resident #1 had a pressure skin injury he acquired during his stay at the facility. A r… | 2020-09-01 |
| 65 | 65 | VALLE VISTA MANOR | 275021 | 402 SUMMIT AVE | LEWISTOWN | MT | 59457 | 2017-10-12 | 201 | D | 1 | 1 | BU9C11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure a resident was assisted with an appropriate discharge plan, when the resident wanted to immediately leave the facility, to ensure the resident's ongoing needs were met, but the facility had determined that long term care was necessary, for 1 (#1) of 10 sampled residents. Findings include: During an interview on [DATE] at 6:00 p.m., staff member C stated that resident #1 was discharged from the facility on [DATE]. Staff member C stated that resident #1 was discharged because the facility could not meet his needs per staff member B. Staff member C stated that resident #1 did not have an initial discharge plan, as he was considered to be a long term resident, and could not return to live in the community. Staff member C stated that after the resident left the facility, and had been taken to the hospital, the hospital had not notified the facility directly when resident #1 was discharged from the hospital. Review of the resident's Discharge Return Anticipated MDS, with an ARD date of [DATE], showed in Section Q, under Discharge Plan, A was coded as a 1 which is for a yes meaning active discharge planning was already occurring for the resident to return to the community. The MDS contradicted what staff member C had stated relating to long term care placement. Review of resident #1's Resident Incident Report, dated [DATE] at 9:18 p.m., showed resident #1 became increasingly verbally angry with facility staff, and he stated he wanted to leave in his vehicle. When resident #1 would not calm down, staff member P phoned staff member B and was informed of the situation. Staff member B advised staff member P to contact law enforcement, due to the resident's behavior. Resident #1 was escorted from the facility by law enforcement, although a discharge plan had not been initiated for the resident, prior to the resident leaving the facility. Further review of the incident report for reside… | 2020-09-01 |
| 66 | 66 | VALLE VISTA MANOR | 275021 | 402 SUMMIT AVE | LEWISTOWN | MT | 59457 | 2017-10-12 | 241 | D | 0 | 1 | BU9C11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident had clothing available in his closet to attend the evening meal for 1 resident (#8); and failed to return laundered clothing to resident owners for two residents (#s 9 and 11) of 13 sampled and supplemental residents. This had the potential to affect all residents who receive clothing from the facility laundry. Findings include: 1. Resident #8 was admitted to the facility with [DIAGNOSES REDACTED]. Review of resident #8's care plan, with a revision date of 10/6/17, reflected staff was to anticipate the resident's needs and address them. Review of the resident #8's Admission MDS, with the ARD of 9/21/17, reflected the resident required the extensive assistance of one staff member to dress. During an observation and family interview on 10/11/17 at 5:00 p.m., resident #8 was wearing a white T-shirt and had no clothes hanging in his closet. Resident #8's family member voiced the resident did not have any clothes hanging in his closet, and this was not the first time he did not have clothes available to him from the laundry. The family member stated the resident had several pairs of sweat bottoms and shirts in the facility, and stated the resident would not want to go to dinner without a shirt on. Staff member H came into the resident's room to assist him to the evening meal in the dining room. Staff member H was told resident #8 did not have any clothes in his closet. Staff member H was told by the family member that the resident needed a shirt to go to dinner. Staff member H stated she would look in the laundry for the resident's clothing. Staff member H returned to the resident's room and stated his clothing was clean, in the laundry room, and would probably be delivered the following day. Staff member H had brought one of the resident's shirts with her. Staff member H assisted resident #8 to put on his shirt. During an interview on 10/12/17 at 9:10 a.m… | 2020-09-01 |
| 67 | 67 | VALLE VISTA MANOR | 275021 | 402 SUMMIT AVE | LEWISTOWN | MT | 59457 | 2017-10-12 | 243 | E | 0 | 1 | BU9C11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to make all residents aware of upcoming resident group meetings in a timely manner and encourage resident attendance. This had the potential to discourage all residents from attending group meetings and prevent expression of resident concerns regarding care received by the facility, and affected 3 (#s 9, 11, and 12) of the 13 sampled residents. Findings include: During an interview on 10/10/17 at 4:50 p.m., staff member [NAME] was requested to assist to notify residents of a special resident group meeting planned to allow residents to express concerns and complaints to state surveyors, without the presence of facility staff. She agreed to do so, saying she would advertise it like she did resident group council meetings. She stated she would post the scheduled meeting on the activities calendar outside her office in the hall and also would verbally invite residents who she knew were active members in the facility's regular resident group meeting. Staff member [NAME] was asked to recruit some of the facility CNA staff to speak with all the residents and let them know they were all invited to the meeting. During an observation of a resident group meeting, scheduled for 10/11/17 at 10:45 a.m., the following was noted: Ten minutes before the meeting, staff member [NAME] said that residents were not showing interest in attending the meeting, and said she thought maybe only 2 or 3 were planning on attending. NF1 overheard this statement, and went from resident to resident relaying the purpose of the meeting. Within ten minutes, eight residents had gathered, and the meeting was started at 10:55 a.m. Two of the residents, #s 9 & 11, stated during the meeting they had not been previously informed of the meeting. Resident #12 said the resident group council meetings were not well advertised and sometimes only two or three residents attended, even though the meetings were held at the… | 2020-09-01 |
| 68 | 68 | VALLE VISTA MANOR | 275021 | 402 SUMMIT AVE | LEWISTOWN | MT | 59457 | 2017-10-12 | 244 | E | 0 | 1 | BU9C11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to consider the views of the facility's group resident council and respond to resident grievances and recommendations. This had the potential to affect all the residents in the facility, and did affect resident #12 and #13. Findings include: A review of resident #12's MDS, with an ARD of 8/10/17, showed a BIMS of 13: cognitively intact. During an observation and interview of the resident group meeting held on 10/11/17 at 10:55 a.m., resident #12 said she felt there was a need for greater communication between the group council members and the facility administration. She said during resident council meetings the residents have been given only a short time to express their concerns, and have not been given any time for discussion. She said the meeting minutes have been being taken by a facility staff member, who relayed the resident concerns to the administration or other facility departments. She said the resident group members did not hear back about their expressed concerns. The group was not sure their complaints were even being heard. She described the group meetings as rushed and driven by the agenda as verbalized by the staff person taking the meeting minutes. The meeting was not ran by the residents. She said many of the residents don't even get a chance to talk, especially if they have slow speech or speech impairments, and Then we're just blown off because we don't matter. During an observation and interview of the resident group meeting held on 10/11/17 at 10:55 a.m., resident #13 said that the reason he had quit coming to the resident group council meetings was because the facility did not respond to the resident's complaints. He said that he felt that the facility nurses and CNAs worked hard and did excellent work, but that there were too few of them to be able to meet the needs of all the residents who needed care at the same time. He said he had complained o… | 2020-09-01 |
| 69 | 69 | VALLE VISTA MANOR | 275021 | 402 SUMMIT AVE | LEWISTOWN | MT | 59457 | 2017-10-12 | 253 | D | 0 | 1 | BU9C11 | Based on observation and interview, the facility failed to maintain exterior doors for pest control due to impaired doors seals for 1 of 1 kitchen exterior door. Findings include: During an observation on 10/10/17 at 3:14 p.m., the exit door from the kitchen to the outside was inspected. The rubber seal at the bottom of the door was peeled away and was bent preventing a proper seal under the door. The screen door installed in the same place also lacked proper seal on the bottom of the door to accommodate proper pest control. Staff member D, who accompanied the surveyor, stated the rubber seal would be replaced. | 2020-09-01 |
| 70 | 70 | VALLE VISTA MANOR | 275021 | 402 SUMMIT AVE | LEWISTOWN | MT | 59457 | 2017-10-12 | 280 | D | 0 | 1 | BU9C11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to update and revise the care plan for 1 (#4) out of 10 sampled residents. This failure had the potential to confuse staff members as to the appropriate precautions to be taken to prevent the resident from potential harmful falls. Findings include: Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. He was not ambulatory, secondary to lower extremity weakness, and required staff assistance to transfer. During an observation of the facility's South Dining Room, on 10/10/17 at 3:45 p.m., resident #4 was observed in his Broda chair with his feet resting on the lower footrests. His upper torso was stretched forward, out of the chair, with his arms and full upper body weight resting on the dining room table before him. With his right facial cheek against the table cushioning his head, his eyes were closed, and he appeared to be sleeping. His Broda chair was not locked in position. Two other residents were in the room sitting in wheelchairs at dining tables several feet away. They were calling out for staff help for unknown reasons. No staff was in the room or in the nearby hall. Resident #4 had been in the dining room since lunch. A review of resident #4's fall incident reports and care plan showed the resident had multiple falls from (MONTH) (YEAR) through (MONTH) (YEAR). Resident #4's care plan also showed the following: I need staff to transfer me into a recliner in South Dining Room after all my meals. Initiated: 04/18/17. A review of resident #4's care plan, under a focus regarding him as a high fall risk, showed the following on page number eight: Do not leave me unsupervised in my Broda at any time. If I stay in my Broda I must be in a location where staff can supervise my activity. Otherwise I should be transferred into a recliner or into my bed. Date initiated: 04/18/2017. During an interview, on 10/12/17 at 12:10 p.m., staff member A said t… | 2020-09-01 |
| 71 | 71 | VALLE VISTA MANOR | 275021 | 402 SUMMIT AVE | LEWISTOWN | MT | 59457 | 2017-10-12 | 281 | D | 0 | 1 | BU9C11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to perform physician ordered urinary catheter irrigations for 1 (#4). This failure had the potential to increase the resident's risk of [MEDICAL CONDITION] and urinary tract infection; and the facility failed to monitor a resident for dysphagia symptoms of choking, coughing, and emesis during meals, and failed to monitor lung sounds before and after meals for 1 (#8) resident out of 10 sampled residents. Findings include: 1. A review of resident #4's medical record showed the [DIAGNOSES REDACTED]. He had an indwelling urinary catheter with a [DIAGNOSES REDACTED]. He was readmitted on [DATE]. During an observation and interview with resident #4, on 10/10/17 at 3:45 p.m., it was noted that the resident's urine, as it flowed through his urinary catheter tubing, contained a large amount of white particle sediment in yellow clear urine. A review of resident #4's TARS for (MONTH) and (MONTH) of (YEAR) showed the following: Flush catheter with sterile water and vinegar solution daily and PRN, one time a day related to urinary tract infection, site not specified. Start Date - 08/26/17 0730. Further review of resident #4's TARS, showed that between the dates of 9/1/17 and 10/10/17, the resident received urinary catheter irrigations every day except for 9/1/17, 9/11/17, 9/12/17, 9/13/17, 9/22/17, 9/28/17, 9/29/17, 9/30/17, 10/2/17, 10/5/17, and 10/6/17. Out of a period of 40 days the resident did not receive catheter irrigations as ordered for 11 days, or 27.5 % of the time. It was noted that on 10/7/17 and 10/8/17 the resident received catheter irrigations that were signed off as given on a PRN (as needed basis). During an interview on 10/11/17 at 7:30 a.m., staff member G stated that resident #4 had a history of [REDACTED]. She said that whenever resident #4 received his urinary catheter irrigations, two staff people needed to be present because the resident's behavior can be inap… | 2020-09-01 |
| 72 | 72 | VALLE VISTA MANOR | 275021 | 402 SUMMIT AVE | LEWISTOWN | MT | 59457 | 2017-10-12 | 371 | E | 0 | 1 | BU9C11 | Based on observation, interview, and record review, the facility failed to monitor and remove outdated food items stored in the resident snack storage refrigerator, in the locked pantry across the hall from the nurses' station. This failure had the potential to affect all residents who consumed outdated food from the snack storage refrigerator. Findings include: During an observation of the facility's locked pantry across the hall from the nurse's station on 10/11/17 at 1:55 p.m., inspection of the snack storage refrigerator contents showed the following: - A 16 oz. container of[NAME]Caramel Dip, previously opened and dated 9/14/17. - A round glass container of soup, labeled with a first name, and dated 9/30/17. - A jar of Famous Dave's pickle chips, labeled with a first name, and dated 9/14/17. - A container of cranberry juice, dated 10/10/17. - Four half bologna and cheese sandwiches in sandwich bags, all dated 10/8/17. During an interview during the observation of the facility's locked pantry, on 10/11/17 at 1:55 p.m., staff member H said that all food kept in the refrigerator for longer than three days was considered outdated and needed to be disposed of. She stated that it was the responsibility of the CNAs on night shift to monitor and discard outdated food in the resident snack refrigerator. She said she would dispose of the above outdated items, and then she proceeded to do so. During an interview on 10/12/17 at 8:02 a.m., staff member F stated the dietary department was responsible for the monitoring and disposal of foods outdated in the resident snack refrigerator. A review of the facility's policy, titled Foods Brought by Family/Visitors, showed the following: Perishable foods must be stored in re-salable containers with tightly fitting lids in the refrigerator. The nursing staff is responsible for discarding perishable foods on or before the use by date. The nursing and/or food service staff must discard any foods on or before the use by date. | 2020-09-01 |
| 73 | 73 | VALLE VISTA MANOR | 275021 | 402 SUMMIT AVE | LEWISTOWN | MT | 59457 | 2017-10-12 | 514 | E | 0 | 1 | BU9C11 | Based on record review and interview, the facility failed to ensure residents received a bath or shower at least one time per week, and the medical record reflected the provision of baths/showers, for 3 (#s 5, 7, and 10) out of 10 sampled residents. This had the potential to affect all resident's receiving baths in the facility. Findings include: 1. Review of resident #7's care plan, with a review date of 8/2/17, reflected resident #7 required extensive assistance of one staff member to take a bath. The care plan reflected resident #7 needed nail care weekly, usually on her bath days. Review of resident #7's bath record reflected she received two baths in the month of (MONTH) (YEAR). Resident #7 did not receive a bath from (MONTH) 1 through (MONTH) 11, at which time she was given a bath on (MONTH) 12. The bath record reflected resident #7 did not receive a bath from (MONTH) 20 through (MONTH) 1, (YEAR). She received a bath on (MONTH) 2, (YEAR). The medical record lacked evidence of the nail care and bathing each week. During an interview on 10/12/17 at 8:45 a.m., staff member N stated if the resident refuses a bath the electronic charting has a refused option that can be chosen that will show the resident refused. Staff member N stated residents received their baths at least weekly. A request for the facility policy and procedure for resident baths was requested. No policy and procedure was received prior to the end of the survey. 2. A review of resident #10's medical record showed he entered the facility on 9/21/17 with an open left knee wound, which was draining. A review of the facility's resident Bath Schedule showed resident #10 was scheduled to receive a shower/bath twice a week. A review of resident's #10's care documentation showed he received his first shower/bath in the facility 15 days after his admission. During his 21 days in the facility he received only one scheduled bath on 10/7/17, and another unscheduled two days earlier on 10/05/17. The medical record lacked evidence of the showers or baths twi… | 2020-09-01 |
| 74 | 74 | VALLE VISTA MANOR | 275021 | 402 SUMMIT AVE | LEWISTOWN | MT | 59457 | 2018-11-15 | 641 | D | 0 | 1 | MIUW11 | Based on record review and interview, the facility failed to accurately code a Quarterly MDS for 1 (#41) of 12 sampled residents. Findings include: Review of resident #41's Quarterly MDS, with the ARD of 10/23/18, showed the resident had an ostomy, but was always incontinent of bowel; had a catheter, but was incontinent of urine; had experienced dehydration, vomiting, fever, and internal bleeding during the 7 day look-back period. Review of resident #41's medical record did not show an ostomy, or an episode of illness in October, (YEAR). During an interview on 11/14/18 at 1:32 p.m., staff member L did not know why those items were coded on the MDS. She stated, I don't think the resident has an ostomy, and he wasn't sick. It is because I am new at the job. | 2020-09-01 |
| 75 | 75 | VALLE VISTA MANOR | 275021 | 402 SUMMIT AVE | LEWISTOWN | MT | 59457 | 2018-11-15 | 658 | D | 0 | 1 | MIUW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the faciltiy staff failed to meet professional standards of quality by not wearing gloves when removing and replacing a narcotic patch, [MEDICATION NAME], for 1(# 31) of 14 sampled and supplemental residents; and staff failed to dispose of a [MEDICATION NAME] appropriately. Findings include: 1. No Glove Use During an observation and interview on [DATE] at 4:25 p.m., staff member A removed a narcotic patch from resident #31. Staff member A did not wear gloves to remove the existing patch and to apply a new patch. Staff member A stated she was not sure if, and why, she should be wearing gloves to remove and replace a [MEDICATION NAME]. During an interview on [DATE] at 8:45 a.m., staff member A stated she should have worn gloves during the patch change for resident #31 to prevent self-contamination from direct skin contact with the narcotic patch. Review of the facility's policy, Medication Administration and Ordering, read, .7. Never handle medications with bare hands. 2. [MEDICATION NAME] disposal During an observation and interview on [DATE] at 4:27 p.m., staff member A disposed a [MEDICATION NAME] removed from resident #31. Staff members A and B co-signed in the Controlled Substance Record Book indicating the used patch was disposed of. Staff member A stated the co-signature was not always obtained when disposing of the [MEDICATION NAME]es. During an interview on [DATE] at 4:31 p.m., staff member F stated two nurses should have witnessed the disposal of a [MEDICATION NAME], and co-signed the destruction of the patch. Staff member F stated the destruction of [MEDICATION NAME]es were not always witnessed and co-signed by a second staff member because, We sometimes get too busy. A review of the Controlled Substance Record Books #25 and #26, for the North corridor, showed the following for resident #31: - [DATE]; only one staff member signed on page 82 when then [MEDICATION NAME] was disposed o… | 2020-09-01 |
| 76 | 76 | VALLE VISTA MANOR | 275021 | 402 SUMMIT AVE | LEWISTOWN | MT | 59457 | 2018-11-15 | 686 | D | 0 | 1 | MIUW11 | Based on observation, records review, and interview, the facility failed to prevent and identify the development of a Stage II pressure ulcer, and failed to assess the progress of the pressure area for 1 (#20) of 12 sampled residents. Findings include: During an observation on 11/15/18 at 9:13 a.m., resident #20's coccyx showed evidence of a healing pressure area. Calazine was applied to the areas by staff member F. Staff member F put on gloves and opened a drawer, and applied the lotion without changing to clean gloves. Review of resident #20's progress note, dated 9/26/18, showed residents wife brought to this RN's attention that resident had a sore on his bottom. Resident does not report pain, has difficulty remembering to alert staff of needs, is incontinent at times, and prefers to sit in recliner throughout the day. The wound was assessed measuring 1.0 x. 6 x 0.2, Stage II. No intervions were implemeneted for the pressure sore, despite the above identified causes. During an observation on 11/13/18 at 11:30 a.m., resident #20 was sitting in his recliner; he did not have a pressure reducing cushion in his recliner, or on his wheelchair. During an interview on 11/15/18 at 9:13 a.m., staff member F stated the wife took the ROHO cushion for the recliner home. She did not know why. Review of a progress note dated, 11/5/18, showed the wound was closed with some scabbing. Review of the medical record showed no other assessments or measurements regarding the pressure area. Review of the Admissions MDS, with the ARD of 8/23/18, showed no pressure reducing device for the bed or chair, and no turning and reposition program. During observations on 11/13/18 at 11:35 a.m., 11/14/18 at 10:41 a.m., 11/14/18 at 1:57 p.m., and 11/15/18 at 10:26 a.m., resident #20 was sleeping in his recliner without a pressure reducing cushion, or position changes. Review of resident #20's weight report showed a significant weight loss, with no additional calories or protein to promote healing. Review of the Care Plan, dated 10/18/18, did not… | 2020-09-01 |
| 77 | 77 | VALLE VISTA MANOR | 275021 | 402 SUMMIT AVE | LEWISTOWN | MT | 59457 | 2018-11-15 | 692 | D | 0 | 1 | MIUW11 | Based on observation, interview, and record review, the facility failed to identify a significant weight loss for 1 (#20) of 12 sampled residents. Findings include: During an interview on 11/12/18 at 11:40 a.m., resident #20's family member was getting the resident ready for lunch out of the facility. She stated the resident did not like the food at the facility. Upon their return to the facility, resident #20's family stated he loved his lunch, and it was the most she had seen him eat in a long time. She stated he had lost 77 pounds in the past year. During an observation on 11/15/18 at 8:36 a.m., resident #20 ate 1/2 of a piece of ham and drank his liquids. He did not eat his eggs, English muffin, or cereal. He was not offered any other meal replacement. Review of resident #20's Food Preferences Interview showed it was blank, other than Oatmeal at breakfast every day. During an interview on 11/15/18 at 1:05 p.m., staff member H stated it was the responsibility of the Account Manager to collect food likes and dislikes. She was not aware of resident #20's significant weight loss. Review of resident #20's Nutritional Assessment, dated 8/28/18, showed, Resident is sleeping soundly at this time and no family present. No nutrition concerns at this time. Review of resident #20's Weight Summary, dated 11/2/18, showed a 5 percent weight loss in one month and a 7.5 percent loss in 3 months. Review of resident #20's Care Plan, dated 8/28/18, showed, I need staff to observe for and report changes in my abilty to feed myself or amount eaten for meals. Review of resident #20's Meal Record, from 9/15/18 to 11/14/18, showed the resident ate less than 51 percent or refused 80 meals out of 130 meals recorded. During an interview on 11/15/18 at 12:41 p.m., staff member N stated resident #20 does not have a big appetitie. | 2020-09-01 |
| 78 | 78 | VALLE VISTA MANOR | 275021 | 402 SUMMIT AVE | LEWISTOWN | MT | 59457 | 2018-11-15 | 732 | B | 0 | 1 | MIUW11 | Based on observation, interview, and record review, staff failed to ensure the Daily Posting of staffing information had been updated daily, was accurate and current, had all data requirements; including the facility name. This practice has the potential of affecting all residents residing at, and visitors of, the facility. Findings include: During an observation on 11/13/18 at 12:45 p.m., the Daily Posting of Hours of Nurse Staffing sheet, posted near the nurse's station, had not been updated since 11/5/18. The posted information sheet also lacked the facility's name. During an interview on 11/13/18 at 4:06 p.m., staff member A stated she was not sure when, or by whom, the Daily Posting of Hours for nurse staffing was completed. A review of the Daily Posting of Hours showed the sheets had not been updated from 10/16/18 through 10/24/18, and 10/26/18 through 11/3/18. The posted information sheet lacked the facility's name. During an observation on 11/14/18 at 4:44 p.m., the Daily Posting of Hours had not been updated since 11/13/18. The posted information sheet lacked the facility's name. During an observation and interview on 11/15/18 at 1:15 p.m., staff member [NAME] stated the Daily Posting of Hours had not been updated since 11/13/18. Staff member [NAME] stated, The Night-shift (nurse) was responsible for initiating the Daily Posting of Hours, but that nobody was currently responsible for making sure it had been completed. | 2020-09-01 |
| 79 | 79 | VALLE VISTA MANOR | 275021 | 402 SUMMIT AVE | LEWISTOWN | MT | 59457 | 2018-11-15 | 759 | E | 0 | 1 | MIUW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the medication error rate was less than 5%, which affected 1 (#35) of 14 sampled and supplemental residents. The facility medication error rate was 12%. Findings include: During an observation and interview on 11/14/18 at 7:48 a.m., staff member B prepared medications for resident #35. Staff member B stated resident #35 was independent and could self-administer the Metered Dose Inhalers (MDIs) without assistance. At 7:55 a.m., staff member B identified resident #35, seated in the dining room drinking coffee, and the staff member handed the resident her MDIs. Resident #35 inhaled one puff of the [MEDICATION NAME] MDI, then two puffs from the [MEDICATION NAME] simultaneously. Staff member B did not instruct resident #35 to wait 60 seconds between inhalations, or have the resident rinse her mouth with water and spit after the [MEDICATION NAME]. During an interview on 11/14/18 at 2:40 p.m., staff member B stated she should have asked resident #35 to rinse her mouth with water and spit after inhaling the [MEDICATION NAME] (steroid) MDI. Staff member B stated she was not aware the resident should have waited 60 seconds between use of the MDIs. A review of resident #35's (MONTH) (YEAR) Medication Administration Record [REDACTED] - [MEDICATION NAME]; one inhalation one time a day related to [MEDICAL CONDITIONS] with exacerbation. The start date was 10/5/18. - [MEDICATION NAME]; two puffs twice a date related to [MEDICAL CONDITION] with exacerbation. The start date was 10/4/18. During an observation on 11/15/18 at 8:18 a.m., staff member C identified resident #35, seated in the dining room drinking water, and staff member C handed resident #35 her MDIs. Resident #35 inhaled one puff of the [MEDICATION NAME] MDI, then two puffs from the [MEDICATION NAME] simultaneously. Staff member C did not instruct resident #35 to wait 60 seconds between inhalations, or have the reside… | 2020-09-01 |
| 80 | 80 | VALLE VISTA MANOR | 275021 | 402 SUMMIT AVE | LEWISTOWN | MT | 59457 | 2018-11-15 | 805 | D | 0 | 1 | MIUW11 | Based on observation, interview and record review, the facility failed to provide a consistent textured diet prescription, re-evaluate the effectiveness of the prescribed diet, and establish the nutrient content for 1 (#15) of 12 sampled residents. Findings include: During an observation on 11/13/18 at 12:20 p.m., resident #15 received her lunch meal in mugs, which included pureed baked beans, vegetable salad, and chicken, all thinned to the consistency of water. Review of resident #15's meal card showed, Regular Pureed, drinkable pureed. During an interview on 11/13/18 at 12:30 p.m., staff member J stated he had been told the diet was to be thinned to a water-like consistency. During an observation on 11/13/18 at 12:40 p.m., resident #15 was not able to drink out of the mugs. Staff spooned the liquid into her mouth. During an interview on 11/14/18 at 12:40 p.m., staff member N stated resident #15's ability to eat varied day to day. Some days she could use a straw, and mostly drank her chocolate ensure. During an interview on 11/14/18 at 1:43 p.m., staff member H stated resident #15's food should be pudding thick. She then stated it should be nectar thick. Staff member K stated he was just discussing the diet with the dietitian, and they were going to decide what the diet prescription should be. We all need to be on the same page. The nutrient content of the diet was not consistent or identified by the facility. Review of resident #15's weight record showed a weight loss of 25 pounds from 11/17/17 to 11/9/18. During an observation and interview on 11/14/18 , resident #15's food was in a regular pureed form. Staff member I stated it was to be pudding thick and thinned as needed by the CNA's. She stated the dietary department was not allowed to alter any textures. During an interview on 11/15/18 at 1:20 p.m., staff member O stated it was acceptable to have the CNA's thin the pureed food, because it was with water and the resident could drink water. | 2020-09-01 |
| 81 | 81 | ST JOHN'S LUTHERAN HOME | 275024 | 3940 RIMROCK RD | BILLINGS | MT | 59102 | 2019-03-08 | 609 | D | 0 | 1 | SJ2F11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility administration failed to report missing narcotic medication concerns to the required State Survey Agency. The failure had the potential to affect any resident having narcotics delivered or stored at the facility, and this failure increased the risk of misappropriation of resident property related to narcotic medications, due to the lack of thorough management and tracking of missing medications. Findings include: During an interview on 3/7/19 at 10:00 a.m., staff member C was outlining the facility practice for the accounting and security of controlled substances. During the conversation, staff member C stated, We had one episode of a missing controlled substance reported to the DE[NAME] Medication was sent back to pharmacy for re-labeling, and the card [MEDICATION NAME](hypnotic) went missing. See F755 and F761 for event details. During an interview on 3/8/19 at 8:01 a.m., staff member B stated she misspoke the other day (3/7/19), when she said they did not have any issues with missing medications. Staff member B described an incident with missing [MEDICATION NAME] (for pain) and missing Ambien, which occurred on 11/16/18, stating they investigated the incident and reported it to the DE[NAME] Staff member B was asked if the facility reported the incident to the police, and the State Survey Agency, and she stated, No. A review of the facility policy, Loss of Controlled Substances at (facility name), not dated, showed, On 11/16/18, #28 [MEDICATION NAME]/APAP 5/325 and #5 [MEDICATION NAME] (for [MEDICAL CONDITION]) 5 mg were returned from TCN nursing to (facility name) Pharmacy to be relabeled with updated sig/instructions. Pharmacy staff state that these meds were placed in the pick-up basket and the basket was picked up by TCN nursing. Since this was not a dispense, no signature log was created for these meds. When nursing checked in the basket full of meds, the [MEDICATION NAME]/APAP and [ME… | 2020-09-01 |
| 82 | 82 | ST JOHN'S LUTHERAN HOME | 275024 | 3940 RIMROCK RD | BILLINGS | MT | 59102 | 2019-03-08 | 656 | D | 0 | 1 | SJ2F11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to complete a person centered care plan that included interventions for the personal safety of 1 (#76); and failed to develop a comprehensive, person centered activity care , for 1 (#125) of 34 sampled residents. Findings include: 1. During an interview on 3/7/19 at 9:53 a.m., staff member B stated, He is able to go out on the bus independently. He had cigarettes in his pocket when the bus driver picked him up. I know that, because my husband is the driver. She further stated resident #76 had an order for [REDACTED].#76, and had reminded him of the no smoking policy. During an interview on 3/7/19 at 11:00 a.m., staff member L stated when she met with the families she let them know about the no smoking policy. She stated, If I feel that there is a concern identified with regards to smoking, then I would include a Tobacco Free flyer. She stated when resident #76 was admitted , he did sign something acknowledging the no smoking policy. During an interview on 3/7/19 at 1:24 p.m., resident #76 stated he was aware of the no smoking policy in the facility when he was admitted . He stated I don't know why I did that. Review of resident #76's physician progress notes [REDACTED].#76 had recently been caught smoking in his room. The resident had severe [MEDICAL CONDITION] and used oxygen. The progress note showed, He says he smoked because he was stressed about the move to new unit. Review of resident #76's Significant Change MDS, dated [DATE], Section C, showed a BIMS of 15; cognitively intact. Review of the facility document, titled Resident and Service Agreement, dated 6/1/18, and signed by resident #76, showed, under section XII, Miscellaneous, Subsection D, Smoke Free Policy, Resident acknowledges and agrees to comply with Facility's 'Smoke Free' policy as defined in Appendix D. Failure to comply with said policy constitutes Material non-compliance with Agreement. Review of res… | 2020-09-01 |
| 83 | 83 | ST JOHN'S LUTHERAN HOME | 275024 | 3940 RIMROCK RD | BILLINGS | MT | 59102 | 2019-03-08 | 679 | D | 0 | 1 | SJ2F11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide the residents on the transitional care north (TCN) unit with a meaningful activity program for 2 (#s 100 and 434) of 34 sampled residents. Findings include: During an observation 3/6/19 at 1:10 p.m, no activity calendar was posted on the TCN unit. During an interview on 3/06/19 at 1:27 p.m., staff member J said the TCN did not have a formal activities program. She said most of the residents on the TCN unit have OT, PT, and/or ST (therapy services) several times a day, and by the times the residents are done with all that, they just want to rest. a. During an interview on 3/7/19 at 9:39 a.m., resident #434 said she would like to participate in activities. The resident said she was admitted to the facility on [DATE]. She said a staff member had come by and talked to her about what kind of things the resident was interested in. Resident #434 said no one had asked her if she wanted to participate in any activities. Review of resident #434's baseline care plan, dated 3/4/19, failed to identify any activities for the resident. The baseline care plan did not include an activity care plan. Review of resident #434's The Resident History and Preferences LTC Form, dated 3/5/19, showed it was somewhat important for the resident to participate in group activities, and very important for her to participate in her favorite activities. b. During an interview on 3/8/19 at 10:23 a.m., staff member B said, We don't have activities on TCN. The elders (residents) are here to get well and they don't need activities. They have therapy and doctor appointments. They need to rest when they are not at therapy or at other appointments. Review of resident #100's physician's progress note, dated 1/24/19, showed, At this time, she again reiterates that she is not a person that is used to sitting around and being in the nursing facility is causing boredom and depression. She states she is int… | 2020-09-01 |
| 84 | 84 | ST JOHN'S LUTHERAN HOME | 275024 | 3940 RIMROCK RD | BILLINGS | MT | 59102 | 2019-03-08 | 755 | E | 0 | 1 | SJ2F11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure an adequate system was in place for the tracking and control of controlled substances, which were received, stored at, and administered by the facility. The facility failed to identify the risk of diversion for high abuse medications. This failure had the potential to affect any resident who had controlled substances sent to, stored at, or administered by the facility. Findings include: During an observation and interview on 3/6/19 at 9:15 a.m., an opened 30 ml bottle of liquid [MEDICATION NAME] was in an unlocked refrigerator in the medication room. Staff member N stated, We don't count [MEDICATION NAME] with change of shift narc counts, you can't see it through the bottle. We usually measure what's wasted at the end (when bottle was empty). During an interview with staff members A, B, and C, on 3/6/19 at 12:30 p.m., staff member B stated the facility only locks and counts Schedule II medications. Staff member B handed a sheet of paper with language from regulations (Federal) under the old regulatory system, and stated, The language cross walked to the new regs. Staff member B stated, [MEDICATION NAME] (antianxiety) is a Schedule IV not Schedule II. -Staff member C stated, How are we supposed to measure the [MEDICATION NAME] with the dark bottle, you can't see it? -Staff members A & C both stated, Reconciling is not counting. During an interview on 3/6/19 at 1:00 p.m., staff member Q stated, We have never counted liquid [MEDICATION NAME] before, I think we have even discussed it at our administrative meetings. During an interview on 3/7/19 at 10:00 a.m., staff member C stated the system for monitoring the accuracy for Schedule III-V medications coincided with the date on the medication card, and if the nurse tried to order that medication too soon it would be a red flag (alert) in our system. Staff member C stated, The nurses have to document they gave the medi… | 2020-09-01 |
| 85 | 85 | ST JOHN'S LUTHERAN HOME | 275024 | 3940 RIMROCK RD | BILLINGS | MT | 59102 | 2019-03-08 | 761 | E | 0 | 1 | SJ2F11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the supply of Schedule III-V medications were kept to a minimal level; and failed to ensure the Schedule III-V medications were separately locked; and not locked under the same access system used to obtain non-scheduled medications. The above practices had the potential to affect all residents with Schedule III-V medications stored and maintained at the facility. Findings include: During an observation and interview on 3/6/19 at 9:15 a.m., an opened 30 ml bottle of [MEDICATION NAME], a Schedule IV medication, was observed in the refrigerator in the medication room. The refrigerator did not have a separate locking mechanism. Staff member N stated the medication room had a lock, but the refrigerator did not. Staff member N stated the main door to the nursing area needed to be locked if the nurse left the area, but the nurse needed to have a visual on the room if they stepped out. Staff member N stated, We do not count [MEDICATION NAME]. During an interview and observation on 3/6/19 at 12:50 p.m., staff member H stated [MEDICATION NAME], if in liquid form, was in the refrigerator, locked in the closet in the nurses' room. The staff member unlocked the closet door to show where the refrigerator was located. The refrigerator had a clasp and lock, but was not locked. The staff member stated [MEDICATION NAME] and [MEDICATION NAME] were not double locked in any of the facility cottages. Residents with orders for [MEDICATION NAME], in a pill form, or [MEDICATION NAME], had the medications secured with a single lock system, which was in a cabinet, in the resident's room. These medications were not counted in the same manner as the the narcotics and PRN (as needed) medications. Staff member H showed where a resident's single locked medication cabinet was located. The staff member unlocked the cabinet and showed where the resident's [MEDICATION NAME] was located. During an … | 2020-09-01 |
| 86 | 86 | ST JOHN'S LUTHERAN HOME | 275024 | 3940 RIMROCK RD | BILLINGS | MT | 59102 | 2019-03-08 | 880 | D | 0 | 1 | SJ2F11 | Based on observation, interview, and record review, facility staff failed to ensure safe hand hygiene practices, for the prevention of the spread of infections, during the provision of ADL care, when staff moved from a dirty task to a clean task, for 1 (#85) of 34 sampled residents. Findings include: During an observation on 3/6/19 at 7:35 a.m., staff member F assisted resident #85 with toileting and peri care. Staff member F sanitized her hands and put on a pair of gloves, placed a gait belt around resident #85's waist, and transferred him from the bed to the wheel chair. Staff member F wheeled resident #85 to the bathroom, assisted him to stand, pulled his incontinent brief and pants down, and assisted him to sit on the toilet. Staff member F removed, and threw the dirty incontinent brief in the garbage, removed her gloves, and sanitized her hands. Staff member F put a clean a pair of gloves on, placed a clean incontinent brief around resident #85's legs, and assisted resident #85 to stand. Staff member F cleansed resident #85's peri area, and removed her gloves. Staff member F pulled resident #85's clean incontinent brief and pants up and assisted him to sit in the wheel chair. Staff member F did not wash or sanitize her hands after she cleansed resident #85's peri area and removed her gloves. During an interview on 3/7/19 at 8:14 a.m., staff member G stated CNAs are to wash or sanitize hands after changing gloves. Review of a facility hand out, titled, Glove changing and sanitizing during cares showed, . always wash or sanitize before putting on and removing gloves . | 2020-09-01 |
| 87 | 87 | ST JOHN'S LUTHERAN HOME | 275024 | 3940 RIMROCK RD | BILLINGS | MT | 59102 | 2019-08-22 | 580 | G | 1 | 1 | P5VQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the nurse failed to notify a physician for a change of condition that resulted in a hospitalization for 1 (#238) of 38 sampled and supplemental residents. Findings include: During an interview on 8/21/19 at 1:54 p.m., staff member J stated changes of condition such as swelling and desaturation, would be documented in notebooks used by physicians that round in the facility, and then the nurse would call a provider depending on the seriousness of the resident's condition. During an interview on 8/22/19 at 11:16 a.m., staff member B stated a resident that was exhibiting swelling and desaturation, would receive oxygen right away, because it is in the facility's standing orders. The staff are always to let the physician know when a resident exhibited new signs and symptoms by filling out the SBAR form in the folder that the physcians use when rounding in the facility. The nurse should then monitor and use good nursing judgement, in accordance with what the physician recommends, and orders for the resident. Review of resident #238's Respiratory Measurements showed the following: -On 6/20/19 resident #238 had a non-productive spontaneous cough, lungs were clear, and oxygen saturation was measured at 97% on room air. -On 6/26/19 resident #238's cough was described as, Able to clear secretions, Dry, Harsh, Non-productive, Sponateous, Strong. (sic) -On 6/27/19 resident #238's lungs were noted to be clear and diminished at the bases, and was noted to have had, difficulty breathing with activity, Difficulty breathing at rest, Shortness of breath. (sic) Resident #238's oxygen saturation was measured at 89% on room air. -On 6/28/19 resident #238's cough was occasional, productive, spontaneous, strong, and able to clear secretions. Resident #238's oxygen saturation was measured at 88% and 84% on room air. -On 6/29/19 resident #238's lungs were noted to be clear and diminished at bases. Resident #238's oxygen saturatio… | 2020-09-01 |
| 88 | 88 | ST JOHN'S LUTHERAN HOME | 275024 | 3940 RIMROCK RD | BILLINGS | MT | 59102 | 2019-08-22 | 623 | D | 1 | 1 | P5VQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to notify the resident or resident's representative, in writing, of the reason for a transfer for 4 (#s 22, 100, 135, and 238) of 38 sampled and supplemental residents. Findings include: 1. During an interview on 8/21/19 at 8:55 a.m., staff member F stated that resident #100 had sustained a fall with a [MEDICAL CONDITION] which required hospitalization in (MONTH) of 2019. During an interview on 8/22/19 at 10:10 a.m., staff member D stated when a resident has been transferred, she has not given the resident or resident's representative any written documentation related to the reason for the residents's transfer. During an interview on 8/22/19 at 10:15 a.m., staff member C stated when a resident has been transferred, she has not given the resident or the resident's representative any documentation related to the reason for the resident's transfer. During an interview on 8/22/19 at 10:25 a.m., staff member F stated she has done the communication notice, which informs the facility of the change for a resident. She stated the written notices to the resident, or the resident's representative, were done by the staff in Medical Records and Admissions. During an interview on 8/22/19 at 10:30 a.m., staff member [NAME] stated she had not done any written notification to the resident, or the resident's representative, when a resident had been transferred. Review of resident #100's medical record showed she was hospitalized from [DATE] through 6/3/19 for a [MEDICAL CONDITION]. The medical record failed to show a written transfer notification was provided in writing, identifying the reason for the transfer, and given to resident #100 or her representative. The transfer notification documentation was requested for resident #100 on 8/21/19 at 3:10 p.m. No documentation was received prior to the end of the survey. 2. During an interview on 8/21/19 at 3:14 p.m., staff member B stated the facility does… | 2020-09-01 |
| 89 | 89 | ST JOHN'S LUTHERAN HOME | 275024 | 3940 RIMROCK RD | BILLINGS | MT | 59102 | 2019-08-22 | 625 | D | 1 | 1 | P5VQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure a resident or a resident's representative received written information regarding the Bed Hold Policy prior to a transfer, for 3 (#s 22, 100, and 135) of 29 sampled residents. Findings include: 1. During an interview on 8/20/19 at 9:55 a.m., staff member F stated that resident #100 was transferred to the hospital for a [MEDICAL CONDITION] in (MONTH) of 2019. Review of resident #100's medical record failed to show any documentation of the provision of bed hold policy information prior to her transfer to the hospital on [DATE]. During an interview on 8/22/19 at 9:55 a.m., staff member B stated the only bed hold information given to the resident and/or resident's representative was upon admission by the Admission Director. Staff member B stated the facility had not provided any bed hold information upon the transfer to the hospital. During an interview on 8/22/19 at 10:10 a.m., staff member D stated she had not provided any written information to the resident or resident's representative prior to transfer to the hospital. During an interview on 8/22/19 at 10:25 a.m., staff member F stated she had not done any written notifications to the resident or resident's representative regarding the bed hold policy. Staff member F stated she did the communication notice that informed the facility of the change for a resident upon transfer. Staff member F stated the written notices were completed by medical records, and the admissions director. 2. During an interview on 8/21/19 at 3:14 p.m., staff member B stated the facility did not notify the resident or resident's representative of a the bed hold policy upon transfer, but resident #22 was notified at admission. Review of resident #22's Iview Notification, dated 7/24/19, showed, Nurse left voicemail for (name) to return call-called and spoke with (name) and given ok to send to ED (emergency department). (sic) A request on 8/21/19 at 11:0… | 2020-09-01 |
| 90 | 90 | ST JOHN'S LUTHERAN HOME | 275024 | 3940 RIMROCK RD | BILLINGS | MT | 59102 | 2019-08-22 | 658 | D | 1 | 1 | P5VQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, the facility failed to provide services which met professional standards of practice, which involved allowing a resident without an order for [REDACTED]. 1. During a medication administration observation on 8/22/19 at 8:31 a.m., staff member D provided all morning medications to resident #23, and then left the room without waiting until resident #23 had taken all of her medications. During an interview on 8/22/19 at 8:35 a.m., staff member D stated, If the elder is alert, we usually leave the meds (sic) with the elder. Staff member D denied knowledge of a self-administration of medication assessment for resident #23. Staff member D stated she goes back later and checks to make sure the medications were taken. Staff member D was unaware of any order, from the provider, which allowed the medications to be left at the bedside. During an interview on 8/22/19 at 9:14 a.m., staff member B stated there was no policy related to self-administration of medications. Staff member B stated the facility expected the nursing staff to use good judgement when leaving medications at the bedside. Staff member B stated there should be a self-administration of medications assessment, and a physician's orders [REDACTED]. Review of resident #23's Self Administration of Medication Assessment, dated 8/13/15, showed the resident did not desire to self medicate. The handwritten note showed, Nursing to administer meds while pt. @ TCN. All self-administration of medication assessments for resident #23 were requested. No other documents were provided prior to the end of the survey. Review of resident #23's physician orders, dated (MONTH) 2019, failed to show any documentation regarding allowing the self-administration of medications. A policy related to self-administration of medications was requested. No documentation was provided prior to the end of the survey. 2. During an observation and interview on 8/20/19 at 9:0… | 2020-09-01 |
| 91 | 91 | ST JOHN'S LUTHERAN HOME | 275024 | 3940 RIMROCK RD | BILLINGS | MT | 59102 | 2019-08-22 | 758 | D | 1 | 1 | P5VQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, the facility failed to ensure PRN orders for [MEDICAL CONDITION] medications were limited to 14 days, for 1 (#30) of 29 sampled residents. Findings include: During an observation and interview on 8/19/19 at 3:57 p.m., resident #30 was in her wheelchair with a baby doll in her lap. Resident #30 stated, Isn't my baby beautiful? Resident #30 then became tearful when discussing that she had nothing to feed the baby, and would have to give him up because of this. Resident #30 stated, What can you do when you are old and have no money? Review of resident #30's Physician's hospice orders, dated 4/17/19, showed, [MEDICATION NAME] 0.5 mg .take 1 tablet by mouth/sublingual every 4 hours as needed. During an interview on 8/20/19 at 9:55 a.m., staff member F stated that resident #30's moods were like a rollercoaster, and it varied from day to day. Staff member F stated that resident #30 had a gradual decline in mental status, and was placed on hospice in (MONTH) 2019. During an interview on 8/21/19 at 1:00 p.m., staff member I stated, I thought the 14 day limit (for [MEDICAL CONDITION]) was only for prn antipsychotic medications. Staff member I stated that she would review the regulations and follow-up with hospice to see if they have any different rules. No additional information was provided by staff member I. Review of resident #30's Care Team Meeting notes, dated 3/13/19, showed behaviors for the resident included, .shoving, cursing, threatening, yelling . Review of resident #30's Nursing Home Recertification documentation, dated 5/24/19, showed a [DIAGNOSES REDACTED]. [MEDICATION NAME] was listed as a prn medication. The note failed to include documentation of the reason for continuing the use of [MEDICATION NAME] on an as needed (PRN) basis, beyond the 14 day limit. The Impression and Plan section showed, .8. [MEDICAL CONDITION] with anxiety: Well-managed with [MEDICATION NAME] and [MEDICATION N… | 2020-09-01 |
| 92 | 92 | ST JOHN'S LUTHERAN HOME | 275024 | 3940 RIMROCK RD | BILLINGS | MT | 59102 | 2019-08-22 | 759 | D | 1 | 1 | P5VQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, the facility failed to ensure a medication error rate less than 5%. The observed error rate was 12.35%. The errors involved not remaining with the resident to ensure the medications were taken, which included a narcotic, which is a Schedule II medication, for 1 (#23) of 38 sampled and supplemental residents. Findings include: 1. During a medication administration observation on 8/22/19 at 8:31 a.m., staff member D administered the following medications to resident #23: - aspirin 81 mg - calcium with vitamin D 600/400 mg - vitamin D 1000 IU - [MEDICATION NAME] 500/400 mg - Senna Plus 8.6/50 mg - [MEDICATION NAME] 40 mg - [MEDICATION NAME] 600 mg, 2 tablets - [MEDICATION NAME] 20 mg - potassium chloride 20 mEq - [MEDICATION NAME] with [MEDICATION NAME] 5/325 mg After handing the cup containing medications, staff member D left resident #23's room. Staff member D did not observe resident #23 taking the medications given to her. During an interview on 8/22/19 at 8:35 a.m., staff member D stated, If the elder is alert, we usually leave the meds (sic) with the elder. Staff member D denied knowledge of a self-administration of medications assessment for resident #23. Staff member D stated we go back and check later to make sure the medications were taken. Staff member D was unaware of any order from the provider which allowed the medications to be left at the bedside. During an interview on 8/22/19 at 9:14 a.m., staff member B stated there is no policy related to self-administration of medications. Staff member B stated the facility expected the nursing staff to use good judgement when leaving medications at the bedside. Staff member B stated there should be a self-administration of medications assessment and a physician's orders [REDACTED]. Review of resident #23's Self Administration of Medication Assessment, dated 8/13/15, showed the resident did not desire to self medicate. The handwritten not… | 2020-09-01 |
| 93 | 93 | ST JOHN'S LUTHERAN HOME | 275024 | 3940 RIMROCK RD | BILLINGS | MT | 59102 | 2019-08-22 | 761 | E | 1 | 1 | P5VQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, the facility failed to dispose of expired pain, antiemetic, and over-the-counter (OTC) medications for 7 (#s 4, 18, 67, 83, 105, 116, and 117) of 38 sampled and supplemental residents. The facility failed to dispose of an expired floor stock medication and medical supplies; this deficient practice had the potential to affect all residents who utilized the facility's floor stock medication and supplies in the storage area. Findings include: 1. During an observation on 8/21/19 at 10:38 a.m., of the Garden Court (Wing 7) medication cart, the following occured: -one syringe of [MEDICATION NAME] 100 mg/5ml had an expiration date label attached to the syringe barrel which showed 4/19. The Ziplock bag, which the syringe was located in, with the resident label attached, showed an expiration date of 11/19. The syringe was labeled with the name of resident #67. -one syringe of [MEDICATION NAME] HCL 1mg/ml showed no expiration date. The syringe was labeled with the name of resident #83. -one syringe of [MEDICATION NAME] 100 mg/5ml showed no expiration date. The syringe was labeled with the name of resident #18. -one bottle of sodium chloride nasal spray showed an expiration date of 7/19. The bottle was labeled with the name of resident #4. -one box of [MEDICATION NAME] 4mg tablets showed an expiration date of 4/19. The box was labeled with the name of resident #116. -one bottle of Geri-Lanta showed an expiration date of 6/19. The bottle was labeled with Wing 7 stock. During an interview on 8/21/19 at 10:54 a.m., staff member G stated she checked the expiration dates, and looked at them when she pulled tickets for re-order, on Mondays and Thursdays. Staff member G stated, I try to glance at things. I guess that is when I do it. Staff member G did not state how the lack of expiration dates or expired medications were missed during her checks. During an interview on 8/21/19 at 10:56 a.m., staff member H… | 2020-09-01 |
| 94 | 94 | ST JOHN'S LUTHERAN HOME | 275024 | 3940 RIMROCK RD | BILLINGS | MT | 59102 | 2019-08-22 | 880 | E | 1 | 1 | P5VQ11 | > Based on observation, interview, and record review, the facility failed to minimize risks of infection, and to prevent environmental contamination by disposing of sharps containers when the internal contents reached the fill line, subsequently by closing the lid on the sharps containers in four out of four areas. Findings include: 1. During an observation on 8/21/19 at 10:51 a.m., on the Garden Court medication cart, the sharps container, located in the bottom drawer, contained hazardous waste that was filled above the fill line, and the lid was open. During an interview on 8/21/19 at 10:52 a.m., staff member G stated she believed the fill line was at the very top of the container, where the lid is located, not where the actual fill line was marked on the container. 2. During an observation on 8/21/19 at 1:46 p.m., in the Transitional Care Cottage, in the locked medication/supply storage closet, three, overfilled sharps containers were on the floor. The lids on the sharps containers were open, and the containers were filled above the fill line mark. During an interview on 8/21/19 at 1:48 p.m., staff member J stated, When the sharps container is full, we stash them in the medication closet, and then put them in a room in the back. Staff member J stated, Every Friday, environmental services comes and empties them. 3. During an observation on 8/21/19 at 2:31 p.m., in the Hansen Cottage, in the locked medication/supply storage closet, one, full sharps container was on the floor. The lid on the sharps container was open. 4. During an observation on 8/22/19 at 9:18 a.m., in the Liggett Cottage, in the locked medication/supply storage closet, two, full sharps containers were on the floor. The lids on the sharps containers were open. A review of the facility's policy titled, Exposure Control Plan, showed: - Sharps disposal containers are inspected and maintained or replaced by Housekeeping and Nursing Staff whenever necessary to prevent overfilling. -During use, containers for contaminated sharps shall be: -Easily acce… | 2020-09-01 |
| 95 | 95 | ST JOHN'S LUTHERAN HOME | 275024 | 3940 RIMROCK RD | BILLINGS | MT | 59102 | 2017-11-08 | 253 | E | 0 | 1 | 8YVD11 | Based on observation and interview, the facility failed to maintain and repair areas on Wing #7's bath house and the transitional care unit's kitchen to provide a sanitary environment. The facility failed to maintain 2 of 5 cottage exterior doors to prevent potential pest control issues. The facility failed to deep clean one resident's room on Wing #7. This deficiency had the potential to affect the residents who used or occupied these spaces. Findings include: 1. During a fire safety tour observation and interview with staff F on 11/7/17 at 8:53 a.m., Wing #7's bath house was inspected. The door frame of the bath house was damaged, and was not cleanable. The trim at the bottom of the door was hanging off the door and dragging on the floor with sharp nails exposed. The lower portion of the door frame was rotted. The paint, was bubbled and chipped, and rendered the surface uncleanable. Staff member F called the maintenance department on his cellular phone and reported the issue. 2. During a fire safety tour observation and interview with staff G on 11/7/17 at 8:28 a.m., the door to room #727 was open on Wing #7. From the hallway, a heavy accumulation of dust, food (Cheetos and fish shaped crackers), plastic packaging, a piece of garment, and other debris were observed under the bed. The resident was not in the room for interview. Staff member G stated the resident did not refuse housekeeping services. Staff member G stated the resident frequently ate snacks in the bed. Staff member G stated the housekeeping staff worked from 9:00 a.m. to 3:00 p.m., but he did not know the deep cleaning frequencies and procedures. Staff member G did not provide additional information on the room cleaning protocol, including the deep cleaning frequencies, schedules and/or the logs to show when the room was last cleaned, and when the rooms were regularly cleaned. 3. During a fire safety observation and interview with staff L on 11/7/17 at 8:55 a.m., a rectangular piece (measuring approximately 2 inches by 3 inches), of the wood cabin… | 2020-09-01 |
| 96 | 96 | ST JOHN'S LUTHERAN HOME | 275024 | 3940 RIMROCK RD | BILLINGS | MT | 59102 | 2017-11-08 | 278 | D | 0 | 1 | 8YVD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to accurately code the communication, cognition, mood, and pain status, for 2 (#s 11 and 19) of 25 sampled residents. Findings include: 1. Review of resident #11's Significant Change MDS, with the ARD of 9/26/17, showed the resident was always understood and sometimes understands. The Brief Interview for Mental status, showed a score of 0, which reflected severe cognitive impairment. The Mood interview and Pain interview were conducted with the resident. The interviews showed no pain, and no mood indicators. During an interview on 11/7/17 at 3:30 p.m., staff member C stated she did not realize the BIMS assessment should be stopped at question #4 if the resident was unable to answer. She also stated she never looked at Section B, the ability to communicate, and that resident #11's pain and mood interviews may not be accurate, because of her severe cognitive impairment. 2. Resident #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of resident #19's Quarterly MDS, dated [DATE], showed she only sometimes understood communication; she had a BIMS score of 0 (zero) severely impaired, and a PHQ9 of 0 (zero) no mood symptoms. Resident #19's MDS showed her behaviors of inattention, disorganized thinking, and altered level of consciousness, which were continuously present and did not fluctuate. The prior two Annual MDS assessments showed the BIMS assessment and the mood assessment had not been completed by the resident. During an interview on 11/7/17 at 3:35 p.m., staff member [NAME] said she was relatively new to her position and to the MDS process. She said she had not understood that if a person could not respond to the BIMS questions during an interview, the BIMS assessment should be ended. During the BIMS assessment for resident #19, the resident had not been able to directly respond to any of the assessment questions posed. The facility coded 0 for the BIMS summar… | 2020-09-01 |
| 97 | 97 | ST JOHN'S LUTHERAN HOME | 275024 | 3940 RIMROCK RD | BILLINGS | MT | 59102 | 2017-11-08 | 314 | D | 0 | 1 | 8YVD11 | Based on observation, interview, and record review, the facility failed to prevent the development of two avoidable pressure ulcers, and failed to adequately investigate the cause, (with no assessed risk factors) for 1 (# 12) of 25 sampled residents. Findings include: a. Review of resident #12's Quarterly MDS, with the ARD of 8/23/17, showed the development of a Stage II pressure ulcer on the resident's buttocks, on 8/22/17. Review of resident #12's Pressure Injury Report, dated 8/22/17, showed yellow slough. Review of resident #12's Braden Scale, dated 8/30/17, showed a score of 20, meaning no risk factors for developing pressure ulcers. The resident was independent for all care needs. During an interview on 11/8/17 at 2:15 p.m., staff member G stated the pressure ulcer may have developed because resident #12 slept in his recliner. Staff member G stated the facility added a ROHO cushion to the recliner, and resident #12 was a very private man who did not always permit care. Review of resident #12's Care Plan showed as a Stage I to the gluteal cleft, 1 cm x 1 cm on the left side, and 1 cm x 1 cm on the right side. Interventions were the cushion in the recliner, and encourage elder to side lie in bed. The pressure ulcer was documented as healed on 9/18/17. During an interview on 11/8/17 at 3:00 p.m., staff member M stated the pressure ulcer did have yellow drainage and slough. He stated he did not know that slough does not occur with Stage II pressure ulcers. Staff member M stated he believed the pressure ulcer was from friction, and resident #12 needed to be greased up. During an observation and interview on 11/8/17 at 9:20 a.m., resident #10 had a skin cream at his bedside. When asked, he stated he put it on by himself, but it was better when the staff put it on. Staff member M stated it reduced the friction on his bottm. The resident was sitting in his recliner without a cushion. The cushion was next to the recliner. b. Review of resident #12's Care Plan, dated 11/5/17, showed a discoloration to the left medial… | 2020-09-01 |
| 98 | 98 | ST JOHN'S LUTHERAN HOME | 275024 | 3940 RIMROCK RD | BILLINGS | MT | 59102 | 2017-11-08 | 323 | E | 0 | 1 | 8YVD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to identify the root cause analysis to address medications known to contribute to falls, and monitor and modify the effectiveness of interventions for repetitive falls for 3 (#s 10, 12, and 16) of 25 sampled residents. Findings include: 1. Review of resident #10's Fall Data and Plan of Action forms, showed the resident fell four times, which included the following dates: 2/10/17, 4/13/17, 7/2/17, and 10/4/17. Review of resident #10's Root Cause for the fall, dated 2/10/17, showed, Elder - up walking in room. The Plan for new interventions showed, Keep door cracked at night in order to give her a bit of light and so we can keep an eye on her. The facility did not identify why the resident fell while she was walking. Review of resident #10's Root Cause for the fall dated 4/13/17, showed, was looking for a seat in day room after supper and fell trying to maneuver in a tight spot. The Plan for new intervention was walk her back from meal and sit her down in a chair - don't let her wander. The facility did not address the contributing cause of the fall. Review of resident #10's Root Cause for the fall dated 7/2/17, showed, tried turning around to sit down while maneuvering walker and lost balance and fell . The Plan for new interventions showed assist elder in backing up and sitting down. The facility did not address why the residents was unsteady while turning. During an observation on 11/7/17 at 12:40 p.m., resident #10 was walking in the day room with a walker and no assistance. Review of resident #10's Root Cause for the fall, dated 10/4/17, showed, fell when unassisted walk (stand by) on way to bathroom. The Plan for new interventions showed use gait belt and walker while ill with URI. The facility did not identify the contributing factors causing the fall. Review of resident #10's Comprehensive Fall Management Program form, for the falls dated 4/13/17, 7/2/17, and 10/4/1… | 2020-09-01 |
| 99 | 99 | ST JOHN'S LUTHERAN HOME | 275024 | 3940 RIMROCK RD | BILLINGS | MT | 59102 | 2017-11-08 | 328 | E | 1 | 1 | 8YVD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, the facility failed to ensure respiratory care, specifically oxygen therapy, was provided for 3 (#s 6, 26 and 27) of 27 sampled and supplemental residents. Findings include: 1. Resident #6 was admitted with [DIAGNOSES REDACTED]. Review of resident #6's Significant Change MDS, with an ARD of 8/3/17, reflected the resident had a cognitive decline with a BIMS score of 12, moderately impaired. The cognitive decline was added to resident #6's care plan. The MDS reflected resident #6 received the respiratory treatment of [REDACTED].#6 required supervision and set up for her activities of daily living. Review of resident #6's physician orders, dated 4/27/17, reflected an order for [REDACTED]. Review of resident #6's care plan reflected a problem, with the effective date of 4/27/17, for a potential for alteration in gas exchange and ineffective breathing pattern related to heart failure. The goal listed reflected the resident's oxygen saturation level would be maintained at 90%. The interventions listed reflected the resident was to be provided oxygen at up to 2 lpm to maintain a saturation level at or above 90% per nasal cannula. Another intervention reflected resident #6 could operate her concentrator, but generally needed help with turning the portable cylinders on and off that she used to go to activities and meals outside of her room. Another care plan problem, with the effective date of 8/19/17, reflected the resident had a compromised short-term memory as manifested by a BIMS score of 12 (down from 15 on admission). Interventions listed for the problem reflected the resident required staff to reassure her when she was confused, explain all procedures before performing them, and give verbal reminders and cues to assist the resident in orientation. Another care plan problem, with the effective date of 8/10/17, reflected an actual/potential alteration in self-care/ADL ability related to heart … | 2020-09-01 |
| 100 | 100 | ST JOHN'S LUTHERAN HOME | 275024 | 3940 RIMROCK RD | BILLINGS | MT | 59102 | 2017-11-08 | 329 | D | 0 | 1 | 8YVD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to attempt a dose reduction for an antipsychotic and an antianxiety medication for 2 (#s 10 and 12) of 25 sampled residents. Findings include: 1. Review of resident #12's Quarterly MDS, with the ARD of 8/23/17, showed the resident had a [DIAGNOSES REDACTED]. Review of resident #12's Care Plan, initiated 4/4/16, showed a problem for Thought process related to dementia, [MEDICAL CONDITION] with use of [MEDICAL CONDITION] medication, history of chronic pain that can affect thought process, depression, [MEDICAL CONDITION]. The goals included I will be oriented to self daily by responding to my name - by looking at the speaker. The goals and interventions had not been updated since 4/4/16. During an interview and observation on 11/7/17 at 3:30 p.m., resident #12 was alert and oriented, able to respond to all questions, and was friendly and pleasant. Review of resident #12's certification visit by the physician, dated 6/23/16, showed Patient's baseline behavior has improved. He has been receiving [MEDICATION NAME] XR 50 mg (antipsychotic) twice a day. He has been tired in the mornings, most likely due to his [MEDICATION NAME] dose. I'm discontinuing the morning dose keeping [MEDICATION NAME] 50 mg XR daily at 1600. Review of resident #12's Social Service note dated 8/29/17, showed (Resident's) depression score is related to his experienced pain. (Resident) is very independent and travels in the community without assistance. He states that he does worry about falling and hurting himself. (Resident's) memory is good and he has good problem solving capability, if he is not in pain. Pain does cloud his judgement. (Resident) is social and has many friends in the facility. Review of a Pharmacy Note, dated 5/11/17, showed Resident receiving [MEDICATION NAME] at bedtime for [MEDICAL CONDITION]. No mood or behavior documented this review period. Review of a Pharmacy Note, dated 7/18/17,… | 2020-09-01 |
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CREATE TABLE [cms_MT] ( [facility_name] TEXT, [facility_id] INTEGER, [address] TEXT, [city] TEXT, [state] TEXT, [zip] INTEGER, [inspection_date] TEXT, [deficiency_tag] INTEGER, [scope_severity] TEXT, [complaint] INTEGER, [standard] INTEGER, [eventid] TEXT, [inspection_text] TEXT, [filedate] TEXT );